Avoidable Readmissions – Punishing Patients and Providers
The 30 day readmission rule introduced in 2011/12 is an incentive for hospitals to reduce avoidable unplanned emergency readmissions within 30 days of discharge. Section 6.3.2 in the 2014/15 National Tariff Payment System states that “Providers should not be reimbursed for the proportion of readmissions judged to have been avoidable”. Readmissions relating to maternity and childbirth, cancer, chemotherapy and radiotherapy, renal dialysis, organ transplant, young children, emergency transfers, cross border activity and where patients self-discharged against clinical advice are all payable to the provider.
The scheme was designed to encourage providers and commissioners to manage emergency admissions through planned discharges, preventative initiatives, and greater involvement of experienced clinicians. Commissioners must reinvest money they retain from not paying in post discharge services that support rehabilitation and re-ablement. Commissioners are also required to identify patient groups that would most benefit from those services; they must discuss with providers where this money will be reinvested and must insure coordination with other commissioning decisions.
Commissioners are required to set an agreed readmissions threshold and determine the amount that will not be paid for readmissions above this threshold. Setting a threshold requires measuring how many readmissions could have been avoidable, which is a challenge in itself. Separate thresholds can be set for readmissions following elective admissions and readmissions following non-elective admissions.
To perform this process efficiently, a shortlist of patients that experienced an “avoidable readmission” should be made available to the review team. In this list, each patient should be categorised by the provider where an action could have prevented the readmission. This will inform the commissioner where a service gap exists e.g. hospital, primary care, community, social services etc.
The disadvantage of setting a threshold is that if might put pressure on the provider to reduce readmissions but it does not accurately reflect clinical need of the patient or better outcomes. Instead a more advanced systematic solution should be used utilising algorithms that identify avoidable readmissions consistently, month-by-month, case-by-case that are not payable to providers. Also, it might not have been in the provider’s control where follow-up care failed to deliver or the patient did not adhere to the rehabilitation and an emergency readmission was required.
Setting thresholds are a budgetary solution to a clinical problem where a lot of time and money is spent in discussions about what is over the threshold and not payable. Instead a short-list of patients should be compiled by clinical algorithms that are subsequently reviewed by a clinically led team to decide if the provider gets paid or not.
Readmissions are generally indicative of ineffective patient management and call the quality of care provided across the continuum into question. However, while many readmissions are preventable, some are clinically necessary or unavoidable. Our research at i5 Health shows that over 10% of non-elective readmissions within 30 days are on the same day, over 20% on the next day and over 50% after 7 days of being discharged. Considering the short time-frames after discharge, those readmissions are unlikely to be caused by support services outside the control of the provider and are more likely to be due to low quality care.
Readmissions within 30 days generally account for 12%-16% of all admissions whereby avoidable readmissions account for only 2%-3%. If avoidable readmissions can be reduced, capacity can be released at the provider so that more patients can be treated for, the provider will be paid and the healthcare event will be a much more positive experience for the patient.
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