Ef­forts pay­ing off?

Read­mis­sions drop, but hos­pi­tals hit with penal­ties

Modern Healthcare - - COVER STORY - Joe Carl­son

Medi­care of­fi­cials and pol­icy ex­perts long have thought that hos­pi­tals should do a bet­ter job of pre­vent­ing the need for pa­tients to be read­mit­ted soon af­ter their ini­tial dis­charge.

Ini­tial data now sug­gest that years of ef­forts to cut pre­ventable read­mis­sions are fi­nally pay­ing off—though ma­jor ques­tions still linger about which spe­cific mea­sures are work­ing and whether hos­pi­tals are fix­ing the statis­tics with­out ac­tu­ally solv­ing the qual­ity of care prob­lem.

In the mean­time, hos­pi­tals’ rev­enue has taken a hit. A Mod­ern Health­care re­view of CMS data shows that two-thirds of hos­pi­tals have seen pay­ment cuts based on their per­for­mance in pre­vent­ing three types of read­mis­sions—for heart at­tacks, heart fail­ures and pneu­mo­nia. Only one-third of hos­pi­tals were un­af­fected.

The most se­vere fi­nan­cial penal­ties in 201213 con­sist of 1% Medi­care pay­ment cuts. The penal­ties will grow in com­ing years—a sit­u­a­tion that alarms some crit­ics be­cause re­search shows that more cash-strapped hos­pi­tals treat­ing pop­u­la­tions with high rates of chronic ill­nesses are be­ing hit the hard­est by read­mis­sions penal­ties.

“Safety net hos­pi­tals are much more likely to be pe­nal­ized,” said Dr. Ashish Jha, a pro­fes­sor of health pol­icy at Har­vard School of Pub­lic Health.

A com­pre­hen­sive study of six years of Medi­care data, pub­lished last week in the on­line jour­nal Medi­care & Med­i­caid Re­search Re­view, con­cluded that 18.4% of all Medi­care in­pa­tients were read­mit­ted for care within 30 days of dis­charge. That was a de­cline from the pre­vi­ous aver­age rate of 19%, which was sta­ble over the five pre­ced­ing years.

The change meant that roughly 70,000 fewer read­mis­sion cases were seen in hos­pi­tal wards in 2012 than would have been pre­dicted by his­tor­i­cal rates. The study found wide variation among re­gions in changes in read­mis­sion rates. But the au­thors wrote that com­par­ing dif­fer­ences in the data was dif­fi­cult be­cause the data were not ad­justed for dif­fer­ences in lo­cal dis­ease pro­files and de­mo­graphic fac­tors. Still, larger hos­pi­tals in all re­gions of the coun­try tended to have higher rates of read­mis­sions.

“It’s kind of ex­cit­ing to start to see the re­sults tab­u­lated on what di­rec­tion we’re headed,” said Matthew Press, an as­sis­tant pro-

fes­sor of pub­lic health and medicine at Weill Cor­nell Med­i­cal Col­lege in New York. “But closer mon­i­tor­ing and anal­y­sis needs to hap­pen to fig­ure out how and why th­ese read­mis­sions were averted.”

CMS Cen­ter of Medi­care Di­rec­tor Jonathan Blum touted a ver­sion of the data in Fe­bru­ary as “an early sign that our pay­ment and de­liv­ery re­forms are hav­ing an im­pact.”

Last week’s study said it wasn’t clear which ini­tia­tives were caus­ing the dip in read­mis­sions. Was it the pay­ment cuts that went into ef­fect in 2012? Or was it the rise of the con­cept of ac­count­able care or­ga­ni­za­tions, which cre­ate fi­nan­cial in­cen­tives for bet­ter co­or­di­nated care fol­low­ing hos­pi­tal dis­charge? Fed­eral of­fi­cials also have pushed mem­ber­ship in ed­u­ca­tional or­ga­ni­za­tions like the Part­ner­ship for Pa­tients, while forc­ing hos­pi­tals to pub­licly re­port read­mis­sion rates to Hos­pi­tal Com­pare.

Any of those fac­tors could have had an im­pact, the study said.

Jha also noted that hos­pi­tals have clas­si­fied a grow­ing num­ber of pa­tients as out­pa­tients un­der ob­ser­va­tion—which could skew the read­mis­sion num­bers down­ward be­cause they would not be recorded as read­mis­sions if they later were hos­pi­tal­ized.

“Fun­da­men­tally, the ques­tion to me is: Have we re­ally done a good job of pre­vent­ing read­mis­sions, or have we just re­as­signed peo­ple who would have been read­mit­ted to a dif­fer­ent sta­tus?” Jha said. “The jury is still out.”

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