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Under intense scrutiny by CMS and private payors of consumption of healthcare resources — particularly hospitalizations, hospital readmissions and emergency room visits — many healthcare organizations have taken steps to curb avoidable utilization of services in the populations they serve.

In this era of value-based reimbursement, Benchmarks in Reducing Avoidable Healthcare Utilization: Data to Drive Down ER Visits and Readmissions takes a comprehensive look at industry activity in the reduction of hospital readmissions and ER visits as a whole, then drills down to the health plan and hospital perspectives presented by survey respondents. The utilization reduction data documented in this benchmarks report are derived from two separate surveys conducted in 2010 by the Healthcare Intelligence Network, to which a total of 180 organizations responded.

Table of Contents:

• Overview
• Chapter 1: Performance Benchmarks in Reducing Avoidable ER Visits
• Chapter 2: Performance Benchmarks in Reducing Hospital Readmissions
• Chapter 3: Survey Tools

Download the executive summary of 2011 Benchmarks in Reducing Avoidable Healthcare Utilization: Data to Drive Down ER Visits and Readmissions.

Each chapter documents strategies to reduce a specific type of healthcare utilization, identifying current and planned progams, targeted populations, hospital discharge tasks, patient satisfaction, reimbursement models, estimated ROI, and much more, easily discerned in more than 70 easy-to-follow graphs and tables.

1. Benchmarks in Reducing Avoidable ER Visits:

With consensus widespread that much of emergency room use is avoidable and preventable, healthcare organizations like Kaiser Foundation Health Plan of Colorado, WellPoint and many others are working to staunch the flow of avoidable ER use and point low-acuity patients in the direction of appropriate care.

This chapter provides actionable information on the efforts of healthcare organizations to reduce inappropriate use of the ED. It documents trends and metrics from emergency departments across the country that are successfully managing ER utilization. This chapter is based on responses to HIN's e-survey on Reducing Avoidable ER Visits conducted in 2010, during which more than 90 healthcare organizations reported on their current and planned coaching initiatives.

This chapter answers many FAQs on proper utilization of emergency department services:

• How prevalent are programs to reduce avoidable ER use, and what kind of results do they net?
• Which populations and conditions are responsible for most preventable ER visits?
• What are the most effective ways to redirect patients to more cost-effective and appropriate healthcare settings?
• How do organizations promote programs and educate patients about proper use of healthcare services?

This chapter also provides expanded data on the following:

• The percentage of respondents faced with avoidable ER use;
• Percentage of respondents with programs in place to more efficiently manage ER use;
• Top populations contributing to avoidable ER use;
• High utilizers or 'frequent flyers' of ER services and the conditions most frequently presented by high utilizers;
• 25 successful strategies healthcare organizations are using to engage primary care physicians in ER utilization efforts;
• Reducing avoidable ER visits by patients recently discharged from the hospital;
• The most effective staffing assignments to discourage inappropriate ER visits;
• Program promotion and patient education ideas;
• Sector-specific results from hospitals and health plans that responded to this survey; and much more.

This industry snapshot is enhanced with advice and lessons learned from Kaiser Foundation Health Plan of Colorado, WellPoint and others, including a Louisiana hospital's strategy for handling psychiatric patients who present in the ER.

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2. Benchmarks in Reducing Hospital Readmissions:

Beginning in 2013, CMS will penalize hospitals for excess readmission rates. Initial focus will be on readmissions for heart failure, acute myocardial infarction and pneumonia data that is already reported on the CMS Hospital Compare Web site.

This chapter quantifies efforts by 90 healthcare organizations to reduce avoidable readmissions in their most vulnerable and high-utilization populations, as reflected by responses to HIN's second annual survey on Reducing Hospital Readmissions, conducted in December 2010. It includes comparative 2009-over-2010 data on key activities, including the single area where efforts to reduce readmissions has doubled and the health professional to which overall responsibility for reducing readmissions has shifted.

This chapter documents efforts to reduce readmissions on the part of long-term care providers. Respondents also describe how they're preparing for increased payor scrutiny of 30-day readmissions and PPACA-mandated posting of hospital readmission rates.

This chapter provides data on the following readmission trends:

• Current and planned readmission reduction programs;
• Populations and conditions targeted by readmission reduction efforts;
• Tools and strategies to identify patients most at risk for returning to the hospital;
• Strategies, protocols and policies to help prevent hospital readmissions in vulnerable populations;
• The top tasks performed at hospital discharge to minimize the chances of a patient returning to the hospital as well as other strategies to strengthen the hospital discharge process;
• Roles and responsibilities in readmission avoidance program administration;
• Emerging trends in reimbursement for 30-day readmission rates;
• Overcoming barriers to reducing readmissions and to the launching of programs in this area;
• The impact of hospital readmission management programs on healthcare utilization, member/patient satisfaction and ROI;