Penalty pro­gram slowed Medi­care read­mis­sions,

but progress has stalled

Modern Healthcare - - NEWS - By Mara Lee

By most ac­counts, the fed­eral govern­ment’s fiveyear cam­paign to stem the tide of hospi­tal read­mis­sions has been a suc­cess. The num­ber of Medi­care ben­e­fi­cia­ries mak­ing a U-turn within 30 days of be­ing dis­charged has been on a down­ward slope ever since re­im­burse­ment dol­lars were at risk un­der the Hospi­tal Read­mis­sion Re­duc­tion Pro­gram.

For ex­am­ple, read­mis­sion rates for Medi­care ben­e­fi­cia­ries suf­fer­ing con­ges­tive heart fail­ure av­er­aged 22% from 2011 to 2014, down from 24.5% from 2005 to 2008, ac­cord­ing to a Kaiser Fam­ily Foun­da­tion anal­y­sis of CMS data. Read­mis­sions for pneu­mo­nia pa­tients fell from 18.2% to 16.9% dur­ing the same pe­riod.

A good thing for pa­tients, re­duc­ing read­mis­sions has also helped cut spend­ing. As re­cently as 2011, all-cause read­mis­sions cost the na­tion $41 bil­lion, ac­cord­ing to a 2014 Agency for Health­care Re­search and Qual­ity re­port. Medi­care’s tab alone was $26 bil­lion an­nu­ally, $17 bil­lion of which was at­trib­ut­able to avoid­able re­hos­pi­tal­iza­tions. By 2014, Medi­care spend­ing on read­mis­sions fell by $9 bil­lion.

While im­prove­ments were made dur­ing the first three years of the read­mis­sions pro­gram, con­cern is mount­ing that mo­men­tum has stalled. There’s been no more than 0.1% re­duc­tion on av­er­age be­tween 2013 to mid-2016, ac­cord­ing to a De­cem­ber 2016 JAMA study.

“It kind of sur­prised us,” said Dr. Ni­har De­sai, a car­di­ol­o­gist at Yale New Haven (Conn.) Health Sys­tem, and lead au­thor of the study, which showed the link be­tween fi­nan­cial penal­ties for read­mis­sions and im­proved re­sults.

The Medi­care Pay­ment Ad­vi­sory Com­mis­sion es­ti­mated that 12% of Medi­care read­mis­sions in 2011 were avoid­able, and that of the 10% of hos­pi­tals who were the worst per­form­ers, 15% were avoid­able. If that’s true, that would sug­gest most hos­pi­tals that went from 22% read­mis­sions for a cer­tain con­di­tion to 20% al­ready achieved 75% of what is pos­si­ble.

The rea­sons for the plateau are com­pli­cated, said Dr. Steve Jencks, whose re­search was in­stru­men­tal in help­ing cre­ate the read­mis­sions pro­gram. For starters, the num­ber of con­di­tions mea­sured has grown from three—heart at­tacks, heart fail­ure and pneu­mo­nia—to six with the ad­di­tion of chronic lung dis­ease, coro­nary artery by­pass graft surgery, and hip and knee re­place­ments. Hos­pi­tals haven’t had as much time to work on the new mea­sures. But, he said, it may also be be­cause af­ter mak­ing ini­tial im­prove­ments, hos­pi­tals are go­ing to have to dig a lit­tle deeper to get the next level, and it may take longer to see re­sults.

“Is this the bot­tom, is what peo­ple are ask­ing, and if not, what is the next set of strate­gies?” said Nancy Foster, vice pres­i­dent for pa­tient safety at the Amer­i­can Hospi­tal As­so­ci­a­tion, adding that ex­perts may have reached the lim­its of sci­en­tific knowl­edge on how to re­duce read­mis­sions.

“Is this the bot­tom, is what peo­ple are ask­ing, and if not, what is the next set of strate­gies?” Nancy Foster Vice pres­i­dent for pa­tient safety at the Amer­i­can Hospi­tal As­so­ci­a­tion

The Hospi­tal Read­mis­sion Re­duc­tion Pro­gram was a sig­nif­i­cant part of the Af­ford­able Care Act’s ef­forts to not only con­trol costs, but push providers to im­prove out­comes. The first round of penal­ties for high rates of read­mis­sions took hold in 2012, with roughly 2,000 hos­pi­tals col­lec­tively tak­ing a $290 mil­lion hit. Penal­ties could to­tal $528 mil­lion in 2017, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion.

The penal­ties have worked, De­sai’s study strongly sug­gests. Im­prove­ments were rapid for hos­pi­tals that learned in 2010 that they were likely to be pe­nal­ized for tar­geted con­di­tions, with de­clines of 1.3 to 1.72 points a year over the next two years on av­er­age. Com­pare that with im­prove­ments of about 0.8 points in non­tar­get con­di­tions.

At hos­pi­tals that were al­ready be­low av­er­age—where im­prove­ments were hap­pen­ing faster than the oth­ers be­fore the read­mis­sion pro­gram’s ex­is­tence—con­di­tions that weren’t tar­geted de­clined about 0.54% a year, and there was no sig­nif­i­cant de­cline in the tar­geted con­di­tions.

“Our data should sug­gest places that were not pe­nal­ized seemed to have con­ducted broad read­mis­sion ini­tia­tives that re­duced read­mis­sions for every­one,” De­sai said.

Hos­pi­tals tack­led the is­sue in both treat­ment—try­ing to stan­dard­ize best prac­tices to avoid com­pli­ca­tions—and by beef­ing up dis­charge planning and care co­or­di­na­tion.

Renown Health,

a not-for-profit health sys­tem that serves a 17-county re­gion in north­ern Ne­vada and north­east­ern Cal­i­for­nia, used $9.8 mil­lion in grant money from the Cen­ter for Medi­care and Med­i­caid In­no­va­tion to in­cor­po­rate paramedics into a care-co­or­di­na­tion pro­gram in hopes of im­prov­ing ser­vices for pa­tients at home. Dur­ing in-home vis­its, paramedics go over the pa­tient’s dis­charge plan, pro­vide ed­u­ca­tion and med­i­ca­tion rec­on­cil­i­a­tion and re­in­force the im­por­tance of fol­low-up ap­point­ments. The pro­gram saved $9.6 mil­lion over three years and Renown de­cided to keep fund­ing it af­ter the grant ended.

Joanne Scil­lia, Renown’s vice pres­i­dent of pop­u­la­tion health man­age­ment, said the paramedic pro­gram saw Med­i­caid and Medi­care Ad­van­tage pa­tients, and de­liv­ered con­sis­tent re­duc­tions in read­mis­sions for pa­tients with con­ges­tive heart fail­ure, chronic ob­struc­tive pul­monary dis­ease and heart at­tacks.

Care-man­age­ment teams at Renown also call re­cently dis­charged pa­tients and check that home health aides or Meals on Wheels is on the way. Nurses also ask how pa­tients are feel­ing and about lin­ger­ing symp­toms.

Renown, which is an ac­count­able care or­ga­ni­za­tion, tracks all-cause read­mis­sions by all pay­ers and looks at the fig­ures non-risk-ad­justed. From April 2016 through March, 11.38% were read­mit­ted within 30 days, and the sys­tem’s goal is 10.32% by a year from now. In heart at­tacks, Renown is be­low the goal, and within a tenth of a per­cent­age point for pneu­mo­nia. COPD rates stand at 18.03% with a goal of 14.84%; with heart fail­ure, the rate is 18.57% and the tar­get is 16.82%.

“Al­though we’re do­ing well by na­tional statis­tics, we don’t want to rest on our lau­rels,” Scil­lia said. “Our CEO, Tony Slonim, is in­volved in this, and he’s driv­ing this for the or­ga­ni­za­tion.”

In fed­eral fis­cal 2017, Renown’s two hos­pi­tals in Reno, Nev., were as­sessed penal­ties. Renown Re­gional Med­i­cal Cen­ter owed 0.31% in penal­ties, and South Mead­ows Med­i­cal Cen­ter owed just 0.03% in penal­ties, ac­cord­ing to a Kaiser Health News anal­y­sis of CMS data.

At the 1,500-bed Yale New Haven sys­tem, ef­forts to curb read­mis­sions are con­tin­u­ally evolv­ing.

Dr. Ohm Desh­pande, di­rec­tor of uti­liza­tion re­view and clin­i­cal re­design for the sys­tem, said the first ini­tia­tive they tried was to email each at­tend­ing physi­cian who had a pa­tient re­turn within 30 days and ask if there were spe­cific in­ter­ven­tions that could have been done.

“We found only 2.5% to 5% of those emails re­sulted in a clear process miss or mis­take,” he said. “That was just not su­per help­ful.”

Then Yale asked some of the high­est-per­form­ing in­pa­tient care man­agers or dis­charge plan­ners to be­come tran­si­tional care man­agers, with a 70-100 per­son caseload, strad­dling in­pa­tient and out­pa­tient de­liv­ery.

Yale also fo­cused on im­prov­ing charts while the pa­tient was still in the hospi­tal. Pre­vi­ously, clin­i­cians didn’t have a

clear picture of which pa­tients may have had heart fail­ure or COPD be­cause a DRG wasn’t as­signed un­til three to five days af­ter dis­charge. Now, nurses who re­view charts are as­sign­ing a work­ing DRG within 48 hours of the pa­tient’s ar­rival.

“Clin­i­cal doc­u­men­ta­tion is to max­i­mize pay­ment, given the care given,” Desh­pande said. “What we’ve found is it has huge ef­fects on our qual­ity scores as well.”

Na­tional Qual­ity Fo­rum CEO Dr. Shan­tanu Agrawal said hos­pi­tals have plucked the low-hang­ing fruit.

Desh­pande de­scribed one such ini­tia­tive, where Yale has in­vested a lot of ef­fort, but not yet moved the nee­dle. The health sys­tem dis­cov­ered that pa­tients trans­ferred to a skilled-nurs­ing fa­cil­ity were the most likely to re­turn within 30 days. There was also a large de­gree of vari­abil­ity in the read­mis­sions de­pend­ing on skilled-nurs­ing fa­cil­ity.

At one nurs­ing home, Desh­pande said, 45% of pa­tients re­turned within 30 days. So Yale used a com­bi­na­tion of mea­sures—CMS star rat­ings, how re­spon­sive the fa­cil­ity was to co­or­di­nat­ing with Yale, and in­ter­nal data on read­mis­sions—to iden­tify pre­ferred providers. Over­all, the nurs­ing homes that are not rec­om­mended by Yale have read­mis­sion rates 24% higher than the pre­ferred group.

The pro­por­tion of pa­tients

who go to the pre­ferred nurs­ing homes has not in­creased, even though Yale has asked tran­si­tional-care nurses to sug­gest those fa­cil­i­ties. For fis­cal 2017, Yale’s penalty is 1.91% of its Medi­care reim- burse­ment, Kaiser Health News re­ported , still well be­low the 3% max­i­mum, but the high­est in the state of Con­necti­cut.

De­sai’s pa­per spec­u­lated that im­prove­ments stalled af­ter the first penal­ties were levied be­cause ex­ec­u­tives re­al­ized the size of the penalty was smaller than it would cost to try to ad­dress the is­sue. “It was much, much smaller than they were ex­pect­ing,” De­sai said. But he said he doesn’t be­lieve it’s po­lit­i­cally fea­si­ble to make the penalty bite more. “The Amer­i­can Hospi­tal As­so­ci­a­tion and other groups have re­ally, re­ally been firm in their op­po­si­tion to this. Even the cur­rent pro­gram, they were strongly op­posed to. The idea of go­ing up is re­ally not vi­able at all.”

The AHA’s Foster sug­gested that stiffer penal­ties would ac­tu­ally drive up read­mis­sions. “It would take away the re­sources to do this co­or­di­na­tion, which would be sad,” she said, adding that the hospi­tal group will con­tinue to ad­vo­cate for a for­mula that takes a pa­tient’s so­cio-eco­nomic sta­tus into con­sid­er­a­tion.

As pol­i­cy­mak­ers, re­searchers and providers as­sess the on­go­ing ef­fec­tive­ness of the read­mis­sions pro­gram, they’ll likely have to over­come a cul­tural hur­dle as well—keep­ing peo­ple mo­ti­vated. Desh­pande said Yale lost ground on heart fail­ure even as pneu­mo­nia and heart at­tack read­mis­sions im­proved.

“I don’t think we have had the same ur­gency that we did at that time,” he said, re­fer­ring to 2012 and 2013. “I think it’s be­cause we haven’t found an easy in­ter­ven­tion.”


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