Top per­form­ers notch lower Medi­care spend­ing

Modern Healthcare - - A SUPPLEMENT TO MODERN HEALTHCARE - By Mike Mitka

New data from Tru­ven Health An­a­lyt­ics show that many top-per­form­ing hos­pi­tals are sav­ing money for the Medi­care pro­gram. Ac­cord­ing to an ex­clu­sive study Tru­ven con­ducted for Mod­ern Health­care, data show the best per­form­ers in Tru­ven’s 100 Top Hos­pi­tals study do bet­ter in re­duc­ing Medi­care spend­ing for in­pa­tient ad­mis­sions and post-dis­charge, re­sult­ing in higher over­all qual­ity scores and greater pa­tient sat­is­fac­tion.

Tru­ven’s top-per­form­ing hos­pi­tals also reg­u­larly out­pace their peers across a va­ri­ety of clin­i­cal, fi­nan­cial and per­for­mance met­rics, in­clud­ing achiev­ing fewer pa­tient com­pli­ca­tions, fewer read­mis­sions and lower costs per dis­charge.

Jean Chenoweth, se­nior vice pres­i­dent of per­for­mance im­prove­ment and the 100 Top Hos­pi­tals pro­gram at the Ann Arbor, Mich.-based data and an­a­lyt­ics firm, said she’s not sur­prised that the top per­form­ers achieve lower Medi­care spend­ing.

“High-per­form­ing hos­pi­tals on a na­tion­ally bal­anced score­card ac­tu­ally have high bal­anced per­for­mance across the or­ga­ni­za­tion, which has an im­pact on re­duc­ing Medi­care spend­ing,” she said. “The out­come of fewer read­mis­sions and lower costs over­all re­flect the changes that have hap­pened with the con­tin­uum of care. And that’s a proxy for re­fo­cus­ing on greater pa­tient-cen­tered care.”

Medi­care spend­ing per ben­e­fi­ciary, or MSPB, has been in­cluded as a test met­ric for the past year in Tru­ven’s method­ol­ogy for de­ter­min­ing the hos­pi­tals that qual­ify for the an­nual 100 Top Hos­pi­tals list. It was added this year as a part of Tru­ven’s key per­for­mance mea­sures—in­clud­ing 30-day mor­tal­ity rates, 30-day read­mis­sion rates and sever­ity-ad­justed av­er­age length of stay—for iden­ti­fy­ing the 100 Top Hos­pi­tals. MSPB is based on the most re­cent in­for­ma­tion from the CMS’ Hos­pi­tal Com­pare data­base and is risk-ad­justed.

An MSPB episode in­cludes all Medi­care Part A and Part B claims paid dur­ing the pe­riod three days prior to a hos­pi­tal ad­mis­sion through 30 days post-dis­charge. When Tru­ven looked at MSPB for 2,560 hos­pi­tals, re­flect­ing 5.3 mil­lion dis­charges in fis­cal 2013, it found that over­all for the or­ga­ni­za­tions on the 100 Top Hos­pi­tals ros­ter, lower MSPB was cor­re­lated with bet­ter over­all per­for­mance com­pared with all hos­pi­tals with higher MSPB.

The dif­fer­ences in MSPB var­ied by re­gion, us­ing

the U.S. Cen­sus Bureau’s di­vi­sions. The 100 Top Hos­pi­tals ver­sus all hos­pi­tals showed sig­nif­i­cantly bet­ter per­for­mance in East South Cen­tral (70% had lower MSPB com­pared with all hos­pi­tals), Pa­cific (63%) and Moun­tain (60%). The 100 Top fared less well in New Eng­land (31% had lower MSPB com­pared with all hos­pi­tals), Mid­dle At­lantic (36%) and West South Cen­tral (45%).

There also were dif­fer­ences in MSPB based on hos­pi­tal own­er­ship struc­ture. Tru­ven found that 52% of non-sys­tem hos­pi­tals—those that are not part of a larger health sys­tem— had lower MSPB com­pared with all hos­pi­tals, while 46% of hos­pi­tals in the 100 Top study that are part of health­care sys­tems had lower MSPB com­pared with all hos­pi­tals.

Tru­ven re­searchers con­cluded that among the 100 Top Hos­pi­tals, more fa­vor­able over­all per­for­mance is as­so­ci­ated with lower MSPB. Un­planned read­mis­sions were lower and length of stays shorter, while pa­tient sat­is­fac­tion and pa­tient-safety per­for­mance were higher.

On the other hand, the Tru­ven study found that 30-day mor­tal­ity, heart fail­ure mor­tal­ity and pneu­mo­nia mor­tal­ity trended slightly higher at hos­pi­tals with lower MSPB, pos­si­bly in­di­cat­ing that lower Medi­care spend­ing in some cases could carry neg­a­tive con­se­quences de­spite over­all higher qual­ity scores. David Foster, Tru­ven’s lead sci­en­tist, could not fully ex­plain th­ese find­ings. “It could be that maybe the use of cer­tain types of brand-name ver­sus generic drugs or dif­fer­ences in wound care could im­pact ad­versely on mor­tal­ity,” he said.

As for the find­ing that non-sys­tem hos­pi­tals have lower MSPB than hos­pi­tals in a larger sys­tem, Foster spec­u­lated that could be re­lated to lead­er­ship struc­ture. “The ad­min­is­tra­tors and lead­er­ship in a hos­pi­tal have more abil­ity to ef­fect change than in a sys­tem,” he said. “In a sys­tem, you’re deal­ing with mul­ti­ple hos­pi­tals with a fair amount of het­ero­gene­ity, so the chal­lenge is to in­te­grate pol­icy across a sys­tem that is more com­plex.”

Some hos­pi­tals di­rectly fo­cus on re­duc­ing their Medi­care spend­ing per ben­e­fi­ciary, us­ing the MSPB num­bers as a bench­mark. Oth­ers find re­duced Medi­care spend­ing is a byprod­uct of qual­ity and pa­tient-safety ini­tia­tives they have im­ple­mented.

At St. Joseph Mercy in Ann Arbor, Mich.—which has been on the 100 Top Hos­pi­tals ros­ter seven times since 1996—ad­min­is­tra­tors, physi­cians and nurses re­cently started us­ing the MSPB data to im­prove ser­vice qual­ity and pa­tient safety.

Dr. Mark Cowen, chief of clin­i­cal de­ci­sion ser­vices for the hos­pi­tal’s par­ent, St. Joseph Mercy Health Sys­tem, also based in Ann Arbor, said MSPB of­fers in­for­ma­tion about what hap­pens to pa­tients leav­ing the hos­pi­tal, which sub-acute nurs­ing fa­cil­i­ties they use, and whether they are ad­mit­ted to an­other hos­pi­tal. He said the trends, along with billing data, of­fer in­sights the sys­tem’s lead­ers wouldn’t oth­er­wise have for th­ese pa­tients.

Those data can be used to steer pa­tients to post-acute fa­cil­i­ties with bet­ter qual­ity of care. “We are try­ing to work on bet­ter out­comes for pa­tients once they leave the hos­pi­tal,” he said. “We are do­ing part­ner­ships with sub-acute nurs­ing fa­cil­i­ties and nurs­ing homes re­gard­ing the pa­tients we send them.”

In con­trast, at Poudre Val­ley Hos­pi­tal in Fort Collins, Colo., which has been on the 100 Top Hos­pi­tals list nine times, MSPB trends are viewed more as a byprod­uct of the hos­pi­tal’s qual­ity and safety ini­tia­tives, said CEO Kevin Unger. “We’re al­ways look­ing at our com­pli­ca­tion rates and try­ing to drive them down and re­duce our out­liers for pa­tient safety,” he said. “We also fo­cus on our read­mis­sion rates and use elec­tronic health records, for ex­am­ple, to re­duce du­pli­ca­tion of testing.”

Re­gard­less of how the find­ings are used cur­rently, MSPB is ex­pected to be­come a more im­por­tant fac­tor as the CMS moves away from fee-forser­vice pay­ment to value-based pay­ment mod­els such as bun­dled pay­ments for hip re­place­ments and con­ges­tive heart fail­ure treat­ment. That’s be­cause MSPB can be used as a global mea­sure of ef­fi­ciency when providers are re­quired to meet cost and qual­ity tar­gets for de­fined pop­u­la­tions of pa­tients.

“We know we have to pro­vide higher qual­ity at a lower cost, and that’s what’s spurring us to make sure we’re re­ally stream­lined and us­ing our re­sources as ap­pro­pri­ate,” Unger said. His hos­pi­tal is track­ing Medi­care spend­ing as a met­ric for its per­for­mance.

Cowen sees MSPB data help­ing providers fo­cus on both cost and qual­ity. “Medi­care is try­ing to con­trol the cost and im­prove qual­ity and safety at the same time, such as look­ing at read­mis­sions to im­prove qual­ity as well as not hav­ing to pay for a hos­pi­tal­iza­tion,” he said. “That mes­sage res­onates with physi­cians who have some al­tru­ism rec­og­niz­ing there’s waste.”

Tru­ven’s Chenoweth said the find­ings from Tru­ven’s study can serve as a path for­ward for hos­pi­tals. “This is just the be­gin­ning,” she said. “The learn­ing process will go on for a decade or more as we move from the highly mea­sured fo­cus in the hos­pi­tal to fo­cus­ing mea­sure­ment across the full con­tin­uum of care.”

“We are do­ing part­ner­ships with sub-acute nurs­ing fa­cil­i­ties and nurs­ing homes re­gard­ing the pa­tients we send them.” Dr. Mark Cowen St. Joseph Mercy

Health Sys­tem

“We’re al­ways look­ing at our com­pli­ca­tion rates and try­ing to drive them down and re­duce our out­liers for pa­tient safety.”

Kevin Unger Poudre Val­ley Hos­pi­tal

The strong­est per­form­ers in Tru­ven Health’s 100 Top Hos­pi­tals na­tional study not only out­pace their peers on a broad spec­trum of clin­i­cal and fi­nan­cial met­rics, their Medi­care spend­ing is also less per ben­e­fi­ciary.

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