Cur­ing Medi­care’s hos­pi­tal read­mis­sions penal­ties

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man and Steven Ross John­son

Nes­tled within the 996 pages of the 21st Cen­tury Cures Act that Pres­i­dent Barack Obama signed into law last week is a change to the way hos­pi­tals are judged when pa­tients are un­nec­es­sar­ily read­mit­ted.

The law re­quires Medi­care to ac­count for pa­tients’ back­grounds when it cal­cu­lates re­duc­tions in its pay­ments to hos­pi­tals un­der the Hos­pi­tal Read­mis­sions Re­duc­tion Pro­gram.

Un­til the pas­sage of the Cures Act— a bun­dle of leg­is­la­tion aimed at fos­ter­ing bio­med­i­cal in­no­va­tion that, on its way to be­com­ing law, turned into a smor­gas­bord of health­care poli­cies— thorny ques­tions about ad­just­ing for pa­tient de­mo­graph­ics had been raised and stud­ied but not ad­dressed in the struc­ture of the read­mis­sions re­duc­tion pro­gram.

Pre­vent­ing read­mis­sions can be com­pli­cated to man­age for hos­pi­tals in im­pov­er­ished ar­eas, where pa­tients might be un­able to af­ford med­i­ca­tion or healthy food, or they lack trans­porta­tion to at­tend check­ups with pri­mary-care doc­tors.

Those hos­pi­tals nev­er­the­less face fi­nan­cial penal­ties un­less their read­mis­sion rate falls be­low the na­tional aver­age. They and their ad­vo­cates have been ar­gu­ing for years that the frame­work un­fairly de­pletes the re­sources of hos­pi­tals that care for the most vul­ner­a­ble pa­tients.

The other side of the ar­gu­ment is that cre­at­ing dif­fer­ent rules for those hos­pi­tals al­lows fa­cil­i­ties that serve low-in­come com­mu­ni­ties to pro­vide lower-qual­ity care. The pro­gram al­ready risk-ad­justs us­ing clin­i­cal co-mor­bidi­ties, which are more com­mon in poor com­mu­ni­ties.

Pol­icy ex­perts say that the ef­fec­tive­ness of the risk ad­just­ment called for in the Cures Act de­pends on the de­tails of its im­ple­men­ta­tion, which are scant in the leg­is­la­tion. They have also raised con­cerns that be­cause so­phis­ti­cated, re­li­able risk-ad­just­ment method­olo­gies are in their in­fancy, hand­i­cap­ping for pa­tient de­mo­graph­ics might foster com­pla­cency among some hos­pi­tals or even ex­ac­er­bate health dis­par­i­ties, es­pe­cially along racial lines.

“No­body wants to give a blan­ket pass for hos­pi­tals to de­liver poor care, and we cer­tainly don’t want to fur­ther dis­ad­van­tage any al­ready dis­ad­van­taged pop­u­la­tion,” said Melony Sor­bero, a se­nior pol­icy re­searcher at the RAND Corp.

Cre­ated un­der the 2010 Af­ford­able Care Act, the read­mis­sions pro­gram re­quires Medi­care to cut pay­ments to hos­pi­tals with ex­cess 30-day read­mis­sions for cer­tain con­di­tions. That list of con­di­tions has ex­panded from

the orig­i­nal three—heart at­tack, heart fail­ure and pneu­mo­nia—to in­clude chronic ob­struc­tive pul­monary dis­ease, hip and knee re­place­ments and coro­nary artery by­pass grafts.

The CMS es­ti­mated it would save $538 mil­lion in fis­cal 2017 from pay­ment cuts to 2,588 hos­pi­tals un­der the pro­gram. About 3,330 acute-care hos­pi­tals and 430 long-term care fa­cil­i­ties are el­i­gi­ble. Penal­ties are capped at 3% of Medi­care in­pa­tient prospec­tive pay­ments.

The Cures Act re­quires the CMS to ad­just penal­ties based on the pro­por­tion of a hos­pi­tal’s pa­tients iden­ti­fied as dual-el­i­gi­ble ben­e­fi­cia­ries, or those who qual­ify for both Medi­care and Med­i­caid.

Those pa­tients are of­ten ex­pen­sive to serve, ac­count­ing for nearly a third of to­tal Medi­care fee-for-ser­vice spend­ing in 2012 de­spite con­sti­tut­ing only 18% of ben­e­fi­cia­ries.

Ac­cord­ing to Dr. He­len Burstin, chief sci­en­tific of­fi­cer at the Na­tional Qual­ity Fo­rum, the risk-ad­just­ment ap­proach may ben­e­fit safety net hos­pi­tals the most, since it would al­low for “ap­ples to ap­ples” com­par­isons. Burstin said it might also en­cour­age hos­pi­tals to ad­mit the most vul­ner­a­ble pa­tients, while money saved from re­duced penal­ties could be in­vested in com­mu­nity ini­tia­tives for pre­ven­tive health.

But even as they praised the in­tent of the pro­vi­sion, sev­eral ex­perts and hos­pi­tal lead­ers raised ques­tions about how it would work.

In spec­i­fy­ing how the CMS should ad­just for risk, the Cures Act states that the HHS sec­re­tary “shall as­sign hos­pi­tals to groups” and ap­ply “a method­ol­ogy in a man­ner that al­lows for sepa- rate com­par­i­son of hos­pi­tals within each group.” Those groups would be based on hos­pi­tals’ over­all pro­por­tion of dual-el­i­gi­ble in­di­vid­u­als.

The sec­re­tary “may con­sider” the Medi­care Pay­ment Ad­vi­sory Com­mis­sion’s June 2013 re­port, which found that hos­pi­tals with higher pro­por­tions of poor pa­tients tended to have higher read­mis­sion rates and higher Medi­care penal­ties.

The re­port sug­gested set­ting dif­fer­ent tar­get read­mis­sion rates for dif­fer­ent hos­pi­tals, grouped ac­cord­ing to pa­tient pro­files.

For in­stance, hos­pi­tals whose pa­tient pop­u­la­tions are 30% dual-el­i­gi­ble will not be com­pared to hos­pi­tals where dual-el­i­gi­bles are just 2% of the pa­tient mix, said Philip Al­berti, se­nior di­rec­tor for health eq­uity re­search and pol­icy for the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges. Be­yond that, not much is clear. Dr. Michelle Schreiber, se­nior vice pres­i­dent and chief qual­ity of­fi­cer at Henry Ford Health Sys­tem in Detroit, said it will re­quire long-term re­search to iden­tify the most eq­ui­table ap­proach to risk ad­just­ment.

“The vari­ables that will prob­a­bly need to be in­cluded are not only pa­tient-spe­cific but also com­mu­nitylevel vari­ables, such as how stressed is the com­mu­nity,” Schreiber said. “If you’re poor, it in­creases the risk of read­mis­sion, but if you’re also poor in a com­mu­nity with poor re­sources com­pared to a com­mu­nity with rich re­sources—that too is dif­fer­ent.”

This com­plex­ity is one rea­son the CMS has long been wary of in­cor­po­rat­ing some form of risk ad­just­ment for so­cio-eco­nomic fac­tors. The agency and the NQF have been study­ing whether and how to do it.

Although strong ev­i­dence in­di­cates that these fac­tors play a role in health out­comes, re­searchers have yet to fig­ure out how to re­li­ably pre­dict the ef­fects of dif­fer­ent vari­ables.

“These data are dif­fi­cult to cap­ture,” said Fran­cois de Brantes, ex­ec­u­tive di­rec­tor of the not-for-profit Health Care In­cen­tives Im­prove­ment Ini­tia­tive. When de Brantes col­lab­o­rated on re­search to see whether sort­ing pa­tients by ZIP codes in New York City could pre­dict pa­tient out­comes, for in­stance, he and his col­leagues came up empty.

But now that the bill is law, de Brantes said, “it kind of forces the in­dus­try to come up with a so­lu­tion.”

The CMS has been wary of cre­at­ing a lower stan­dard of care for hos­pi­tals serv­ing higher pro­por­tions of low­in­come pa­tients. In 2013 the agency wrote that mak­ing ac­com­mo­da­tions for eco­nomic and de­mo­graphic fac­tors would “sug­gest that hos­pi­tals with low SES (so­cio-eco­nomic sta­tus) pa­tients are held to dif­fer­ent stan­dards for the risk of read­mis­sion than hos­pi­tals treat­ing higher SES pa­tient pop­u­la­tions.”

In­deed, some safety net hos­pi­tals have proved they can per­form as well as any hos­pi­tal on read­mis­sions. The read­mis­sions penal­ties that Medi­care will im­pose in 2017 on mem­bers of Amer­ica’s Es­sen­tial Hos­pi­tals, a trade group rep­re­sent­ing safety net providers, run the gamut, ac­cord­ing to a Mod­ern Health­care anal­y­sis.

Six of 161 or­ga­ni­za­tions (which op­er­ate more than 220 hos­pi­tals and cam­puses) will be pe­nal­ized be­tween 2% and 3% of their in­pa­tient Medi­care pay. But twice as many will see no penalty at all, and many of the AEH mem­bers have im­proved their per­for­mance over the course of the pro­gram.

Pres­i­dent Barack Obama signed the 21st Cen­tury Cures Act into law on Dec. 13.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.