iLoveBenefits: Industry News Blog

Medicaid programs educating beneficiaries

A new AHIP Issue Brief provides background information about the Medicaid program and explains how health plans work with the states to deliver care for Medicaid beneficiaries.

Our issue brief provides an overview of the federal-state Medicaid partnership, who is covered by Medicaid and the benefits they receive, the role of Medicaid health plans, research findings on the value offered by Medicaid health plans, and the key issues health plans face under the Medicaid “mega reg” that CMS is expected to finalize at some point this spring.

The brief also highlights key areas where Medicaid health plans are demonstrating strong leadership:

  • By offering integrated health care delivery systems, Medicaid health plans promote access to coordinated, quality care and prevent overutilization of services that are both unnecessarily costly and potentially harmful for their enrollees, including dual eligibles.
  • By conducting outreach and health education efforts that encourage Medicaid beneficiaries to receive needed preventive care, Medicaid health plans help to reduce unnecessary hospital admissions.

By helping to manage chronic conditions through patient-centric disease management programs, Medicaid health plans are improving health outcomes while also reducing the costs of providing health care to beneficiaries with complex health care needs.

Calling all stakeholders – working together to reduce readmissions

Readmissions become bigger issue for primary care physicians CMS penalties on hospitals with high readmission rates have put pressure on primary care physicians to help keep patients from needing additional inpatient stays. Physicians are using post-discharge care management programs and forming accountable care organizations that focus on performance-based care. Medscape (free registration)

AHRQ Finds Hospital Readmission Rates High Among Medicaid “Super-Utilizers”

Medicaid “super-utilizers” accounted for half of all 30-day hospital readmissions for the Medicaid population in 2012, with a readmission rate nearly six times as high as that for other Medicaid patients, a new statistical brief from AHRQ concludes. Super-utilizers, or patients who had four or more hospital admissions annually, are a relatively small group of patients who account for a disproportionately large share of hospital services and costs. The authors examined data from AHRQ’s Healthcare Cost and Utilization Project and found that the 30-day all-cause readmission rate among super-utilizers was 52.4 percent compared with 8.8 percent for other Medicaid patients. Medicaid super-utilizers’ hospital stays also were longer and more expensive. The two most common reasons for hospitalization among these patients were mood disorders, and schizophrenia and other psychotic disorders.  Medicaid is the largest public health insurance program in the United States, with more than 67 million beneficiaries. The statistical brief is titled, “Characteristics of Hospital Stays for Nonelderly Medicaid Super-Utilizers, 2012.”

The next big issue: use of socioeconomic status in health care

Socioeconomic status, functional ability affect readmission risk, data show Socioeconomic status and functional capacity at home influence a patient’s risk for readmission, and adjusting for these factors addresses some variation in clinical readmission rates, according to research reported in Health Affairs. The Establishing Beneficiary Equity in the Hospital Readmission Program Act, introduced by Rep. Jim Renacci, R-Ohio, would address differences in patient populations that affect readmission risk. The Hospitalist

Building a closed loop process enabling in effective hospital discharges

This is a project funded by AHRQ that is building an infrastructure to support initiatives to reduce avoidable hospital readmissions.

Buffalo, N.Y., university to develop follow-up care pilotThe University at Buffalo School of Nursing received a two-year grant from the Agency for Healthcare Research and Quality for a care transitions program. The grant is to be used for the development of a pilot project designed to ensure appropriate follow-up care after patients are released from the hospital to reduce the need for readmissions and emergency care. Healthcare Informatics online (7/29)

All – Cause 30-Day Hospital Readmission Rates Are Declining

The all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries fell to 17.5% in 2013 from 18.5% in 2012; this rate had held constant from 2007 to 2011 at around 19% to 19.5%. Source: “New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings,” U.S. Department of Health & Human Services, May 7, 2014,

Don’t only focus on what’s wrong with the measure

. . . Focus on what’s rght with the goal.

New HHS preliminary data show an overall 9 percent decrease in hospital acquired conditions nationally during 2011 and 2012. National reductions in adverse drug events, falls, infections and other forms of hospital-induced harm are estimated to have prevented nearly 15,000 hospital deaths, avoided 560,000 patient injuries and saved approximately $4 billion in health spending during that period.

The Affordable Care Act is also helping reduce hospital readmissions. After holding constant at 19 percent from 2007 to 2011 and decreasing to 18.5 percent in 2012, the Medicare all-cause 30-day readmission rate further decreased to approximately 17.5 percent in 2013. This represents an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.

These major strides in patient safety are a result of public-private partnerships and active engagement by patients and families and include efforts from the federal Partnership for Patients initiative and Hospital Engagement Networks, Quality Improvement Organizations, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and many others.


Select to access the HHS news release and the AHRQ methods report.

Data on CMS Readmissions Penalties Now on

For the first time, data from Medicare’s Hospital Readmissions Reduction Program are available on, The Commonwealth Fund’s free health care performance benchmarking tool. These data—unavailable on Hospital Compare—enable users to see which hospitals received penalties (equal to a reduction of 1 percent or 2 percent of their full Medicare reimbursement) for having what the Centers for Medicare and Medicaid Services (CMS) deemed an “excess” number of readmissions among acute myocardial infarction, heart failure, or pneumonia patients over a three-year period. To get started, explore these featured reports:

April 4, 2014 | Categories: data,healthcare,hospitals | Tags: , , | Comments (0)

Leading Health Care Executives Opinions of Health Care Reform

According to a study from the Perelman School of Medicine at the University of Pennsylvania, Nearly two-thirds (65 percent) of the nation’s leading health care executives say they believe the health care system will be somewhat or significantly better by 2020 than it is today as a result of national health care reform. Additionally, 93 percent believe that the quality of care provided by their own hospital or health system will improve during that time period.

Overall, the expected average operating cost reduction was 11.7 percent. These savings could be achieved by such strategies as reducing the number of hospitalizations (54 percent), reducing the number of readmissions (49 percent), and reducing the number of emergency room visits (39 percent).

Source: Perelman School of Medicine at the University of Pennsylvania

The gathering storm: all cause readmissions

Experts recommend focusing on all causes of readmissions
Instead of focusing readmission reduction efforts on improving care for heart attack, heart failure and pneumonia patients on Medicare, health experts suggest hospitals consider all-cause readmissions. Huron Consulting Group’s Laura Jacquin said the CMS may add additional diagnoses to the readmission target list so a focus on all causes is a better route. While an all-cause analysis may be more difficult, experts said risk stratification is one strategy. HealthLeaders Magazine (10/2013)

October 16, 2013 | Categories: healthcare,hospitals | Tags: , , | Comments (0)
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