Medicare Advantage Reduces Preventable Hospital Readmissions

Armen Hareyan's picture

A new analysis of federal and state government data provides further evidence that seniors in Medicare Advantage health insurance plans have lower risk-adjusted hospital readmission rates than patients in Medicare’s traditional fee-for-service (FFS) program, according to a report released today by America’s Health Insurance Plans (AHIP). The study analyzed data from nine states and found reductions in risk-adjusted hospital readmission rates averaging 14-29 percent among seniors in Medicare Advantage compared with Medicare FFS enrollees.

Preventing avoidable hospital admissions and readmissions protects patients from the risks associated with inpatient settings, such as infection, and is an indication that patients are getting the care and services they need on an outpatient basis to stay healthy and avoid complications that can lead to hospital readmissions.

According to a study published in the New England Journal of Medicine, nearly one-fifth (19.6 percent) of Medicare fee-for-service beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34 percent were rehospitalized within 90 days. Moreover, half of patients who were rehospitalized within 30 days did not have a physician visit between the time of discharge and rehospitalization – suggesting that one of the reasons patients ended up back in the hospital was lack of needed follow-up care.

“There is a crisis facing our nation’s health care system with the increase and frequency of preventable hospital readmissions that has significant patient safety and quality implications,” said Karen Ignagni, President and CEO of AHIP. “Health plans have implemented programs that are helping patients get appropriate follow-up care and avoid preventable hospital readmissions and emergency room visits. These programs can serve as a model for policymakers on how to address this important issue.”

Addressing preventable hospital readmissions has been a top priority for policy experts, lawmakers, and health care stakeholders. In fact, the recently enacted Patient Protection and Affordable Care Act of 2010 requires Medicare to establish a hospital readmissions reduction program beginning in 2013. The program would reduce payments to specified hospitals for certain readmissions.

The new AHIP report was based on an analysis of hospital discharge datasets provided by the Agency for Healthcare Research and Quality (AHRQ) as well as state discharge data acquired directly from the states of Pennsylvania and Texas. In the states studied, estimated risk-adjusted readmission rates were about 27-29 percent lower in Medicare Advantage than Medicare FFS per enrollee, 16-18 percent lower per person with an admission, and14-17 percent lower as measured per hospitalization.

This report is the fourth in a series of studies comparing patterns of care among patients with Medicare Advantage coverage and in Medicare’s traditional fee-for-service program. The new nine-state report is an expanded version of a preliminary AHIP report released in September 2009, which showed reductions in certain risk-adjusted readmission rates of 15 percent in California and 33 percent in Nevada.

AHIP has also entered into a partnership with MedAssurant, Inc., a leading health care research and solutions provider, to further study readmission rates among seniors in Medicare Advantage and fee-for-service Medicare. MedAssurant has a large dataset uniquely suited for this purpose. Preliminary findings have yielded similar results to previous AHIP reports, and have been submitted to a medical journal for publication.


“There have been significant changes to the Medicare Advantage program over the past several months,” said Cary Sennett, MD, PhD, MedAssurant’s Chief Medical Officer who is leading the MedAssurant analysis. “We think it vital that policy be informed by research, and are pleased to bring our analytic capabilities to AHIP to assure that this research is available to the policy-making community.”

AHIP also released a new publication that provides company specific examples of the types of programs and services that health insurance plans have implemented to reduce preventable hospital admissions, readmissions, and emergency room visits.

Health Plans To Prevent Hospital Readmissions

· Expanding patient access to urgent care centers, after-hours care, and nurse help lines give patients safe alternatives to emergency rooms for non-emergency care.

· Arranging for phone calls and, in some cases, in-home visits by nurses and other professionals to make sure that follow-up appointments are kept, medications are being taken safely, care plans are being followed, medical equipment is delivered, and home health care is being received.

· Offering intensive case management to help patients at high risk of hospitalization access the medical, behavioral health, and social services they need.

· Arranging for home visits by multidisciplinary teams of clinicians, who provide comprehensive care, teach patients and their caregivers how to take medications correctly, and link families with needed community resources.

· Revamping physician payment incentives to promote care coordination and improved health outcomes.

Written by Robert Zirkelbach