By Lisa Remington
President, Remington’s Think Tank Strategy Institute and The Remington Report
CMS’s report on the Acute Hospital Care at Home (AHCAH) initiative highlighted the highest and lowest readmission rates by medical conditions. The study revealed differences between the AHCAH group and an inpatient comparison group treated in the Hospital at Home program.
This information assists home care providers in evaluating their clinical programs against the medical conditions associated with the highest and lowest readmission rates. We present the findings in detail.
30-Day Readmissions Findings
Results of the 30-day readmissions metric analysis demonstrated some differences across the AHCAH and inpatient comparison groups, with readmission rates being significantly higher in the AHCAH group for two MS-DRGs but significantly higher in the inpatient comparison group for three MS-DRGs.
The highest readmissions rates in the AHCAH group were for two MS-DRGs (DRG 177 and 871) but significantly lower for three other MS-DRGs (191, 194, and 195) . See Table 1.
Table 1.
| DRG | Description | AHCAH Readmission Rate | Comparison Readmission Rate |
|---|---|---|---|
| 177 | Respiratory infections and inflammations with MCC | 16% | 13% |
| 191 | Chronic obstructive pulmonary disease with CC | 14% | 20% |
| 194 | Simple pneumonia and pleurisy with CC | 11% | 15% |
| 195 | Simple pneumonia and pleurisy without CC/MCC | 6% | 13% |
| 871 | Septicemia or severe sepsis without mv >96 hours with MCC | 14% | 12% |
Definitions
DRG (Diagnosis Related Group): These codes determine reimbursement from third-party payers. DRGs are determined by the principal procedure, or the principal diagnosis if no procedure exists, and the presence of other conditions. In the fiscal year 2024, there were 766 DRGs.
MS-DRG (Medicare Severity Diagnosis Related Group): Each of the Medicare Severity Diagnosis Related Groups is defined by a particular set of patient attributes that include principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status.
CC (Complication or Comorbidity): Refers to a secondary diagnosis that adds significant complexity to a patient’s condition, often increasing the required level of care and potentially impacting the length of stay in the hospital, which influences the assigned DRG code and reimbursement level.
MCC (Major Complications or Comorbidities): Describes secondary diagnoses that significantly increase the resources needed to treat a patient’s primary condition. MCCs are more severe than CCs and have a greater impact on a patient’s treatment and resource utilization.
Lisa is a turnaround expert who excels in navigating unsteady, complex, and ambiguous environments. She has provided C-suite education to over 10,000 organizations in the home care sector for decades. Lisa’s trusted voice in the industry has been recognized for her ability to manage disruption, identify new growth and revenue opportunities, and develop high-level engagement strategies between home care and referral partnerships. Her contributions are instrumental in advancing the future of home care.
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