Read­mis­sions penal­ties at work

Ef­fort pushed most hos­pi­tals to re­duce or elim­i­nate penal­ties in sec­ond year

Modern Healthcare - - OPINIONS/EDITORIALS - MER­RILL GOOZNER Edi­tor

There was plenty of good news in the sec­ond-year re­sults from the CMS’ 30-day hos­pi­tal read­mis­sions penalty pro­gram, which was largely over­looked by the press. A large ma­jor­ity of hos­pi­tals ei­ther stayed out of the penalty box or re­duced their fines. Even the mi­nor­ity of hos­pi­tals that ab­sorbed higher penal­ties had a sig­nif­i­cant share that im­proved their read­mis­sions per­for­mance once you fac­tor in the dou­bling of fines this year.

Over­all, 1,370 or 40% of the 3,355 el­i­gi­ble hos­pi­tals re­duced their penal­ties be­tween 2012 and 2013. An­other 912 or 27% stayed the same—no penal­ties in ei­ther year. And the num­ber of hos­pi­tals that re­ceived the max­i­mum penalty dropped sig­nif­i­cantly from 274 in 2012 to 19 in 2013.

Even among the 1,073 or one-third of hos­pi­tals with higher penal­ties, the num­bers sug­gest their over­all per­for­mance ac­tu­ally im­proved. Stony Brook (N.Y.) Univer­sity Hos­pi­tal on Long Is­land, for in­stance, saw its penalty in­crease from the max­i­mum 1% in 2012 to 1.48% in 2013, which is well be­low this year’s max­i­mum penalty of 2%. While read­mis­sions ob­vi­ously re­mained a prob­lem there, the move­ment was in the right di­rec­tion.

The im­proved per­for­mance for most hos­pi­tals wasn’t an overnight af­fair. Medi­care cal­cu­lated last year’s penal­ties based on a rolling aver­age of 30-day read­mis­sions be­tween 2008 and 2011 for three ma­jor con­di­tions—heart at­tack, heart fail­ure and pneu­mo­nia. This year, they ad­vanced the eval­u­a­tion pe­riod by a year. In­clud­ing an­other post-re­form year mat­tered.

It made a dif­fer­ence for Ale­gent Creighton Health Mid­lands Hos­pi­tal in Papil­lion, Neb., which low­ered its read­mis­sions penalty from the max­i­mum 1% in 2012 to zero this year—the most dra­matic re­duc­tion among the 3,355 hos­pi­tals af­fected by the pro­gram. Of­fi­cials at the fa­cil­ity, part of the larger Catholic Health Ini­tia­tives sys­tem, rec­og­nized as early as 2008 that they had ma­jor prob­lems with ex­cess read­mis­sions, es­pe­cially among its con­ges­tive heart fail­ure pa­tients.

“We ini­ti­ated an en­tire care re­design,” said Dr. Jef­fry Strohmyer, a fam­ily medicine doc­tor and cam­pus qual­ity chief at Mid­lands. “We pulled all the stake­hold­ers to­gether, em­ployed ev­i­dence-based treat- ment guide­lines, and ini­ti­ated dis­charge plan­ning from the be­gin­ning of a hos­pi­tal stay.”

The lat­ter part of the pro­gram was cru­cial, he said. They de­ployed case man­agers at the hos­pi­tal to make sure the dis­charged pa­tients were aware of the im­por­tance of tak­ing their med­i­ca­tions and sched­ul­ing fol­low-up ap­point­ments. They even made fol­lowup phone calls within three days of dis­charge to make sure ev­ery­thing was on track. “It’s re­source-in­ten­sive, but that’s what you need to make sure pa­tients have ev­ery­thing they need,” he said.

None of that is com­plex. But it does re­quire some re­sources, and more im­por­tantly, it re­quires the will to get the job done.

Us­ing read­mis­sions penal­ties as a tool to im­prove out­comes has long had its crit­ics within the provider com­mu­nity. Use of a rolling aver­age pe­nal­izes hos­pi­tals long af­ter they have im­proved their per­for­mance.

Safety net hos­pi­tals serv­ing im­pov­er­ished com­mu­ni­ties face a pa­tient pop­u­la­tion that’s more dif­fi­cult to man­age, and they have fewer re­sources. Tar­get­ing spe­cific con­di­tions rather than an all-cause read­mis­sion rate can un­fairly pe­nal­ize some hos­pi­tals.

The CMS has al­ready fac­tored in some of those com­plaints. It elim­i­nated planned read­mis­sions from the over­all cal­cu­la­tion, for in­stance. But CMS of­fi­cials in Bal­ti­more read­ing th­ese re­sults can con­clude only that the pro­gram is hav­ing the de­sired ef­fect, which prob­a­bly means it is here to stay.

For those hos­pi­tals still los­ing ground, the path ahead won’t get any eas­ier. The max­i­mum penalty for the fis­cal year be­gin­ning in Oc­to­ber 2014 es­ca­lates to 3%. Medi­care is also plan­ning to in­clude chronic ob­struc­tive pul­monary dis­or­der and elec­tive ortho­pe­dic op­er­a­tions on its 30-day read­mis­sions eval­u­a­tion list.

The take-home les­son for providers is that a fo­cused ef­fort on qual­ity im­prove­ment has the po­ten­tial to rapidly im­prove per­for­mance. That’s good for pa­tients, who get bet­ter out­comes. That’s good for the CMS and tax­pay­ers, be­cause they get lower costs. And it will be good for providers, who will see the penal­ties shrink to zero—like at Ale­gent’s Mid­lands.

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