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Why hospital readmissions and infections matter

Most people think an insurance company just processes and pays medical claims. At BlueCross BlueShield of Western New York, we do much more. A key way we monitor the quality and cost of health care is by collecting and analyzing medical data.

The members we insure don't like to think about hospitalizations. However, if they have been admitted (or readmitted) to a hospital, or worse yet, have battled a hospital-based infection, this shows the impacts are wide-reaching.

Research shows patients are readmitted because of gaps in care during the transition from the hospital to the home or other settings. Patients often are not clear on care instructions upon being discharged. They may not make follow-up appointments with their primary care physicians, or even understand their medications.

The key to reducing readmissions is managing this critical transition to make certain patients know what to do when they leave the hospital and making certain those patients have proper follow-up care.

In addition to the personal toll hospital readmissions take on patients and their families, the fiscal impacts are significant. The Centers for Disease Control and Prevention cites 4.5 percent of all hospital patients will acquire an infection. The cost to treat these infections is estimated at $18 billion annually.

BlueCross BlueShield works with hospital partners and care agencies to develop collaborative approaches to support improvements that reduce readmissions and infection rates. From May through December 2011, expected member hospital readmissions decreased 7 percent, which resulted in $1.7 million in savings.

Key approaches include:

*Working with hospitals to establish targets for reduced infection rates and readmissions.

*Adding targeted reductions to our hospital incentive programs and reimbursing hospitals when they achieve certain goals. BlueCross BlueShield has committed $10 million for incentives and to help hospitals make up for revenue lost from reduced services.

*At high-volume hospitals, our nurse reviewers consult with hospital discharge planners, review patient charts, and work with physicians to facilitate smooth transitions when patients are discharged, especially for patients at high risk of readmission.

*We arrange for nurses to visit patients at their homes at no cost to the member. Nurses ensure patients have follow-up appointments with their physicians and review medications.

*As needed, nurses will call patients to clarify instructions and ensure care is progressing.

These collaborative approaches improve quality and contain costs for our members and for our community.

@email address/EOS:Raghu Ram, M.D., is vice president and chief medical officer of BlueCross BlueShield of Western New York.