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It uses an "all-cause" definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization. The time frame was set at 30 days because readmissions during this time can be influenced by the quality of care received at the hospital and how well discharges were coordinated.
An existing readmission-reduction program based on payment levels per 30-day episode has shown positive initial results. Maryland will also measure 65 preventable conditions associated with hospital care and seek a cumulative aggregate reduction of 30% on these measures over 5 years.
Medical device maker Medtronic believes there's big money to be made from helping health care providers comply with regulatory mandated reductions in hospital readmission rates. As a result ...
CMS stated that 19 out of 32 pioneer ACOs produced shared savings with CMS. The Pioneer ACOs earned an estimated $76 million. Two Pioneer ACOs generated losses totaling an estimated $4 million. According to CMS the savings were due, in part, to reduction in hospital admissions and readmissions. [13]
Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
The amount of involvement an insurer can have in managing high cost cases depends on the structure of the benefit plan. In a tightly managed plan case management may be integral to the benefits program. In less tightly managed plan, participation in a case management program is often voluntary for patients. [5]
DRGs were intended to describe all types of patients in an acute hospital setting. DRGs encompassed elderly patients as well as new born, pediatric and adult populations. [14] The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget. [11]
NCQA has an on-line reporting tool called Quality Compass that is available for a fee of several thousand dollars. It provides detailed data on all measures and is intended for employers, consultants and insurance brokers who purchase health insurance for groups. NCQA's web site includes a summary of HEDIS results by health plan.