Dual-el­i­gi­bles could of­fer re­lief for hos­pi­tal read­mis­sions penal­ties

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

A new pro­posal from the CMS could ad­dress one of the big­gest con­cerns hos­pi­tal lead­ers have long had with how read­mis­sion penal­ties are cal­cu­lated.

Un­der the pro­posed rule, is­sued April 14, the CMS would for the first time con­sider a hos­pi­tal’s pro­por­tion of dual-el­i­gi­ble pa­tients when de­ter­min­ing penal­ties for or­ga­ni­za­tions with rel­a­tively high rates of read­mis­sions. Although hailed by in­dus­try stake­hold­ers, many said it was an in­cre­men­tal change.

“It’s a good way to start,” said Fran­cois de Brantes, di­rec­tor of the Al­tarum In­sti­tute’s Cen­ter for Pay­ment In­no­va­tion. But Medi­care has been urged for a long time to ex­am­ine ways to ad­just for so­cial and de­mo­graphic fac­tors, he added. “The pro­posed rule­mak­ing still hasn’t fully re­solved that ques­tion.”

The change stems from the 21st Cen­tury Cures Act, which was en­acted in De­cem­ber 2016. The law re­quired Medi­care to take pa­tient back­ground into ac­count when cal­cu­lat­ing pay­ment re­duc­tions un­der the Hos­pi­tal Read­mis­sion Re­duc­tion Pro­gram, and to ad­just those penal­ties based on the pro­por­tion of pa­tients who were du­ally el­i­gi­ble for Medi­care and Med­i­caid.

Such pa­tients are dis­pro­por­tion­ately ex­pen­sive for hospi­tals. Ac­cord­ing to a June re­port from the Medi­care Pay­ment Ad­vi­sory Com­mis­sion, they con­sti­tuted 18% of ben­e­fi­cia­ries yet ac­counted for nearly one-third of to­tal Medi­care fee-for-ser­vice spend­ing in 2012.

Rather than seek com­ment on a sin­gle method, the CMS pro­posal pre­sented dif­fer­ent op­tions for

The CMS’ pro­posed changes, which would take ef­fect in fis­cal 2019 if ap­proved, would help level the play­ing field for hospi­tals serv­ing low-in­come pa­tients, Dr. Bruce Siegel said in a state­ment.

im­ple­ment­ing var­i­ous as­pects of this risk-ad­just­ment strat­egy, such as the data pe­riod used to de­ter­mine dual-el­i­gi­bil­ity and the method used to cal­cu­late and ad­just pay­ments.

For ex­am­ple, it pro­posed bas­ing the ra­tio of the dual-el­i­gi­bles on the to­tal num­ber of Medi­care fee-for-ser­vice and Medi­care Ad­van­tage ben­e­fi­cia­ries. Us­ing both would be more ac­cu­rate, the CMS said, par­tic­u­larly in states with high rates of Medi­care man­aged care. But it also in­cluded an al­ter­na­tive ap­proach: cal­cu­lat­ing dual-el­i­gi­bles us­ing only Medi­care fee-for-ser­vice stays.

Re­gard­less of how the rules are cal­cu­lated, Medi­care-Med­i­caid ben­e­fi­cia­ries are seen as a rel­a­tively consistent group and a clear out­lier in terms of costs, de Brantes said.

“These are re­ally, re­ally com­plex pa­tients,” he said. “This par­tic­u­lar cat­e­gory of in­di­vid­u­als has a bunch of things go­ing on that is just very dif­fer­ent from the gen­eral Medi­care pop­u­la­tion, so ac­count­ing for those dif­fer­ences makes a cer­tain amount of sense.”

Hospi­tals and in­dus­try groups praised the pro­posal as a good first step, even as some of them called for more-com­plex risk ad­just­ment.

The CMS’ pro­posed changes, which would take ef­fect in fis­cal 2019 if ap­proved, would help level the play­ing field for hospi­tals serv­ing low-in­come pa­tients, Dr. Bruce Siegel said in a state­ment. Siegel is CEO of Amer­ica’s Essen­tial Hospi­tals, an in­dus­try group for pub­lic hospi­tals. “But the rule is only the first step to­ward true risk ad­just­ment for our pa­tients’ so­cial and eco­nomic chal­lenges,” he added. “We must go be­yond ad­just­ing only pay­ments to ad­just­ing mea­sures so qual­ity com­par­isons are fair.” He said that Amer­ica’s Essen­tial Hospi­tals hoped the CMS would “ex­tend this ap­proach to other qual­ity pro­grams, when the ev­i­dence for risk ad­just­ment is com­pelling.”

NYC Health & Hospi­tals, the city’s pub­lic hos­pi­tal sys­tem, said that re­view­ing the changes would take some time. Still, “the prin­ci­ple of group­ing hospi­tals who care for sim­i­lar pa­tients is an im­por­tant step in the right di­rec­tion, es­pe­cially for safety- net providers like us,” spokesman Robert de Luna said in a state­ment.

The CMS is also seek­ing com­ments on how sev­eral of its other qual­ity pro­grams, in­clud­ing the Hos­pi­tal Value-Based Pur­chas­ing Pro­gram, Hos­pi­tal-Ac­quired Con­di­tion Re­duc­tion Pro­gram and In­pa­tient Qual­ity Reporting Pro­gram, should ac­count for so­cial risk fac­tors. It is ac­cept­ing com­ments un­til June 13.

“You’ll have a lot of peo­ple crit­i­ciz­ing the ap­proach,” de Brantes said. “Those are fine crit­i­cisms, but the point is, if you don’t start some­where, you never get any place. At least it puts the is­sue on the ta­ble.”

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