AHA Perspective on Readmissions First National Medicare-Medicaid Payment Incentives and Penalties Summit June 1, 2012
Why are readmissions important to policymakers? MedPAC estimates $18B spent on readmissions of Medicare patients within 30 days of discharge Readmission rates vary by major diagnoses and regions of the country Variation signals opportunity for improvement
Policy Changes: Reduce Readmissions What Will Be Expected of Hospitals? More coordination Work with other providers to manage care across episodes More financial risk Opportunity to benefit from efficient care management More Transparency Continued reporting of important quality measures to the public
AHA Perspective Unnecessary readmissions are to be avoided Readmissions are manifestation of many different problems All readmissions are not equal Planned and unplanned Related and unrelated
Unplanned Related Readmissions Should Be Focus Source: American Hospital Association. A Framework for Classification of Readmissions Planned Readmission Related to Initial Admission A planned readmission for which the reason for readmission is related to the reason for the initial admission. Unrelated to Initial Admission A planned readmission for which the reason for readmission is not related to the reason for the initial admission. Unplanned Readmission An unplanned readmission for which the reason for readmission is related to the reason for the initial admission. An unplanned readmission for which the reason for readmission is not related to the reason for the initial admission.
The reasons behind unplanned related readmissions are complex. Hospitals have responsibilities, but they are not alone. Readmissions occur when: Patients don t understand or can t comply with discharge instructions. Patients in some communities lack access to primary care, post acute care, pharmacies. Patients have multiple diagnoses that make them more vulnerable to complications.
Readmissions Reduction Program CMS will start with existing 30-day readmissions measures: heart attack, heart failure, pneumonia ACA: exclude unrelated, planned Hospitals with fewer than 25 discharges for each condition will be excluded Hospitals with excess readmissions penalized up to 1% in FY 2013 Penalties increase in subsequent years
About a third of hospitals will face no penalty while 14% get the maximum of 1%. Readmissions Reduction Program: Percent of Hospitals by Estimated Payment Reduction in FY 2013 Average penalty is $137,000 Max penalty is $2.9 million 305 hospitals are ineligible *No penalty includes hospitals that have too few cases to be eligible for program. Source: FY 2013 Inpatient PPS Proposed Rule.
Readmissions Reduction Program: Key Concerns Current measures do not sufficiently exclude planned and unrelated readmissions Failure to adjust for sociodemographic factors puts safety-net providers at a disadvantage
Readmissions After AMI Discharge: Many Unrelated Top 10 Diagnoses for Readmission (30-day): Heart Attack Source: KNG Analysis of 2009100% Medicare inpatient file and FY2011 Hospital IPPS final rule impact file. Each diagnosis for readmission represents MS-DRGs of multiple severity levels.
Readmissions After Heart Failure Discharge: Many Unrelated Top 10 Diagnoses for Readmission (30-day): Heart Failure Patients Source: KNG Analysis of 2009100% Medicare inpatient file and FY2011 Hospital IPPS final rule impact file. Each diagnosis for readmission represents MS-DRGs of multiple severity levels.
Readmissions After Pneumonia Discharge: Many Unrelated Top 10 Diagnoses for Readmission (30-day): Pneumonia Patients Source: KNG Analysis of 2009100% Medicare inpatient file and FY2011 Hospital IPPS final rule impact file. Each diagnosis for readmission represents MS-DRGs of multiple severity levels.
Risk-adjustment fails to account for some factors that may influence risk of readmission. Risk Adjustment Variables for 30-Day, All-cause Risk Standardized Readmission Rate Following Pneumonia Hospitalization Included in Risk Adjustment Not Included in Risk Adjustment Age Medicare eligibility status (e.g., aged, disabled) Gender Dual eligibility (Medicaid) status or income History of CABG Frailty Condition Categories including: Social support structure History of infection Septicemia/shock Race or ethnicity Cancer Diabetes Geographic region Malnutrition Gastrointestinal disorders Limited English proficiency Hematological disorders Dementia & senility Drug/alcohol abuse Psychiatric disorders Paraplegia, paralysis, et al. CHF & other heart disease Stroke & vascular disease COPD & lung disorders Asthma Pneumonia ESRD or dialysis Renal failure Urinary tract infection Skin ulcers Vertebral fractures Other injuries Source: National Quality Forum. Measure # 0506. www.qualityforum.org. Note: CABG=coronary artery bypass graft; ESRD=end stage renal disease; CHF=congestive heart failure; and COPD=chronic obstructive pulmonary disease.
Failure to adjust for these factors may disadvantage safety net providers. Readmission rates vary for vulnerable populations. Dual eligible status used as proxy for patients that may have access limitations Hospitals that disproportionately serve these populations have higher readmission rates. High dual Hospitals with high DSH patient percentages
Dual-eligibles have higher readmission rates. 30 Day Readmission Rates for Dual and Non-dual Eligible Beneficiaries
Factors leading to higher readmission rates for dual eligible patients are beyond hospital control. As compared to traditional Medicare beneficiaries, dual eligibles are: Much less likely to receive specific measures of preventive care, follow-up care or testing 600% more likely to reside in a nursing facility 250% more likely to have Alzheimer s disease 200% more likely to have a disability 100% more likely to have heart disease 50% more likely to have diabetes 15% more likely to have a cognitive or mental impairment Sources: Kasper, Judy, Molly O Malley, and Barbara Lyons. Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending. Kaiser Commission on Medicaid and the Uninsured, http://www.kff.org/medicaid/8081.cfm, July, 2010. Milligan, CJ et al. Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer, The Commonwealth Fund, February 2008. Grabowski, DC. Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles, Health Affairs, 28 no. 1(2009): 136-146. KNG Health Consulting, LLC 16
Dual eligible patients are not evenly distributed across hospitals. Percent of Dual Eligible Patients for Heart Failure Percent of Hospitals 0 2 4 6 8 10 0 20 40 60 80 100 Percent of Dual Eligible Source: KNG Health Analysis of 2009 100% Medicare inpatient claims data and 2009 100% denominator file. Note: Sample includes hospitals with 25 or more admissions for the condition during a hypothetical 3-year period (i.e. 3 times the number of admissions in 2009).
One Approach: Blend Dual-non/Dual Rates Distribution of RSRR for AMI Density 0.1.2.3 Moderates impact 15 20 25 30 RSRR Weighted Average of Two Scores Single Score
Another Approach: Adjust for DSH Patient Percentage Percentage Reduction in Payment by DSH Patient Percentage Quintile Quintile of DSH Patient Percentage Source: AHA Analysis of Proposed Rule Impact File. 19
Impact of Alternatives KNG Health Consulting, LLC 20
Take Home Message Hospitals and their communities need to become better at avoiding readmissions by improving the reliability of the care provided Congress is willing to achieve cost savings by penalizing hospitals perceived as performing poorly Program needs to be structured fairly to avoid unintended consequences