Learning to Share: Improving Performance and Reimbursement

Blog posted by Nancy Rehkamp (retired)

The hottest topic at most health care conferences is how to achieve quality and performance improvements to assure appropriate reimbursement. Interestingly, payers in many states are collaborating to learn from each other and the various payment models they are testing. The provider side has been less forthcoming about how they are changing their clinical and operational processes and how they are beginning to rethink care delivery.

Achieving the quality and performance goals for hospitals, physicians, and other providers will require us to find ways to share our collective knowledge. The timeframe to implement payment changes, particularly for readmissions and additional hospital-acquired conditions, promises to be ambitious.

The questions I hear most often are what should we measure, and how do we develop our systems to automatically process that information in real time? Many organizations have been working on developing new modes for years, while others have just begun to prepare for reimbursement changes.

Some organizations are focused on clinical diagnostic categories and are breaking down the information by key processes. For example, they might study how the admission or discharge process works for pneumonia patients. Does the process begin in the emergency room? Do they have several visits to a physician prior to being admitted? Do they have any in-home assistance? Is there a standard profile for pneumonia patients either by age, whether or not they live alone, payer source, co-morbidities, or frequency of admissions?

Other organizations, including post-acute and community-based providers, are starting by identifying customers who have frequent admissions and readmissions. They are trying to determine how to make changes that will reduce readmissions. They are exploring interventions such as care coordination, scheduled physician visits, and clinical monitoring technology. One thing that can be said with certainty about planning for payment changes and health care reform is that there is no single right way.

While rethinking facility-based care or home care may be one of the easiest parts of health care reform, readmissions promises to be a far more challenging issue. It is estimated that more than 70 percent of patients who get readmitted within 30 days had gone home without services. These will be the patients whose interventions will be most challenging. We will have to figure out how to work more closely with the family and informal caregivers as well as community services, and this is a new area for many providers.

Historically, we have provided discharge plans and maybe scheduled the first follow-up visit or made a follow-up phone call, but now we will be assuming greater responsibility for how well the transition to and the recuperation at home goes. We are fortunate that we have some time to prepare, develop new tools, and learn what is most effective before payment changes occur. Hopefully, we will also find new ways to share what we learn so that the transition to new payment models is less painful for all organizations.