Reducing readmissions is a key driver of health plan costs and profits, and significantly impacts performance under the Medicare Advantage Star Ratings program. On average, 25% to 35% of Medicare beneficiaries are hospitalized every year, and approximately eight percent of these patients are readmitted within 30 days. These unplanned hospital readmissions increase healthcare costs – including costs for health plans – and are disruptive to patients and caregivers. Unplanned hospital readmissions frequently result in suboptimal patient experiences and outcomes – including an association with increased mortality. A high rate of patient readmissions may indicate inadequate quality of care or a lack of appropriate post-discharge planning and care coordination. Preventing these readmissions can be difficult for plans, however, as they often have little insight into member discharges, especially from post-acute facilities.
Plan All-Cause Readmissions Measure
The National Committee for Quality Assurance (NCQA)’s Plan All-Cause Readmissions (PCR) measure assesses the rate of adult acute inpatient stays that are followed by an unplanned acute readmission for any diagnosis within 30 days of discharge. NCQA recently changed the PCR measure specifications to dramatically expand the inclusion criteria for admissions measured and reported, with the specifications taking effect within the Medicare Advantage Star Ratings Program beginning in Measurement Year (MY) 2021. While the PCR measure has long been a focus area, average health plan performance dropped from 3.3 stars in Star Rating year 2018 to 2.8 stars in Star Rating year 2020. The new measures reflect an increased focus on better care coordination aimed at avoiding unnecessary readmissions.
How Can CarePort Help Payers?
Most health plans have little insight into discharges that are not from an inpatient facility, and require additional support tools and processes following these discharges. In anticipation of modifications to the PCR measure going live in MY 2021, health plan leaders should begin to plan and implement solutions as soon as possible.
CarePort’s extensive national post-acute network and real-time data exchange capabilities enable health plans to track and monitor patients after discharge to ensure each patient continues to receive high quality care post-discharge, regardless of where they receive that care. By tracking patients across the continuum, payers can prevent members from slipping through the cracks, and conduct timely interventions before an unnecessary patient readmission occurs. Leveraging CarePort, payers can experience improved Plan All-Cause Readmissions HEDIS measure scores, as well as the costs savings that accompany reduced readmissions.
This is the second post in our series covering proposed changes to the Medicare Advantage Star Ratings program. In case you missed it, check out our recent blog post regarding the HEDIS Transitions of Care (TRC) measure.
Does your health plan need help achieving readmissions reduction? CarePort can help. Contact us.
