Re­sults of CMS’ readmissions pro­gram has hos­pi­tals, ex­perts ques­tion­ing its pur­pose

Modern Healthcare - - NEWS - By Maria Castel­lucci

The ben­e­fits com­ing from the CMS’ Hospi­tal Readmissions Re­duc­tion Pro­gram have slowed enough that some in­dus­try ex­perts and hospi­tal lead­ers say it may be time to re­tire the pro­gram. The pro­gram was man­dated by the Af­ford­able Care Act as part of a larger ef­fort to curb health costs—readmissions make up about $41 bil­lion in health­care spend­ing—and to mo­ti­vate providers to im­prove out­comes.

By and large, the pro­gram seemed to work. The CMS’ spend­ing on readmissions fell $9 bil­lion by 2014 and 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. But there has been a stand­still on progress. From 2013 to mid-2016, readmissions have only dropped by 0.1% on av­er­age. More­over, since the CMS be­gan to dock U.S. hos­pi­tals for their read­mis­sion rates, a ma­jor­ity have con­sis­tently fallen vic­tim to the penalty.

The mi­nus­cule move­ment now plagu­ing the pro­gram might mean it’s time for the CMS to move on, said Dr. Thomas Bal­cezak, chief med­i­cal of­fi­cer of Yale New Haven (Conn.) Hospi­tal, a safety-net aca­demic med­i­cal cen­ter. The hospi­tal re­ceived a 1.91% penalty this fis­cal year and will be hit with a 1.7% penalty next year.

In 2013, the first year the re­duc­tion pro­gram is­sued penal­ties, 2,217 hos­pi­tals were hit with Medi­care cuts. In its most re­cent round, the CMS ex­pects 2,573 hos­pi­tals will get a penalty in the up­com­ing fis­cal year. Each year, about 75% of the roughly 3,200 af­fected hos­pi­tals see up to 3% of their Medi­care pay­ments re­duced be­cause pa­tients re­turn 30 days af­ter dis­charge. The CMS ex­cludes psy­chi­atric, crit­i­cal-ac­cess and chil­dren’s hos­pi­tals as well as hos­pi­tals in Mary­land be­cause of its unique all-payer rate-set­ting sys­tem.

The CMS did not re­spond to re­quests for com­ment.

Qual­ity pro­gram over­lap

At Yale New Haven Hospi­tal, the readmissions pro­gram not only hurts the bot­tom line, but it no longer makes much sense as the hospi­tal takes part in other CMS value-based care ini­tia­tives such as ac­count­able care or­ga­ni­za­tions, bun­dled pay­ments and the Qual­ity Pay­ment Pro­gram. These pro­grams en­cour­age hos­pi­tals to keep pa­tients healthy and to pre­vent ad­mis­sions in the first place. “It might be time to re­visit this spe­cific stand-alone pro­gram and whether or not it’s time to fold it into other pro­grams,” Bal­cezak said.

A ma­jor com­plaint about the pro­gram has been that readmissions rates aren’t easy for a hospi­tal to con­trol. A pa­tient’s re­turn to a hospi­tal af­ter dis­charge may not have any­thing to do with the qual­ity of care given at a fa­cil­ity. So­cial con­di­tions could be to blame, such as em­ploy­ment sta­tus or sup­port at home, and the area where a pa­tient lives

may make fol­low­ing doc­tor’s or­ders dif­fi­cult or im­pos­si­ble.

Also, be­cause hos­pi­tals aren’t fully equipped to help pa­tients beyond their walls, pol­icy ex­perts—and even some providers—ar­gue that hos­pi­tals have likely done all they can to pre­vent readmissions. In­stead, it’s time for the CMS to fo­cus on other ef­forts that bet­ter ad­dress value-based care, such as bun­dled pay­ments or ACOs. Also needed is more data mea­sure­ment on so­cial de­ter­mi­nants of health, which will of­fer much more in­sight into the health of pa­tient pop­u­la­tions and why they make ex­pen­sive re­turns to fa­cil­i­ties.

“I think when the pro­gram was cre­ated, it was in­no­va­tive,” said Dr. Ashish Jha, a health pol­icy pro­fes­sor at the Har­vard School of Pub­lic Health. “But we are mov­ing to­ward pay­ing for more episodes of care. The point isn’t just to man­age the read­mis­sion, but the en­tire pa­tient and all the ser­vices they need.”

Jha said other CMS pro­grams, such as its bun­dled-pay­ment ini­tia­tive, give much bet­ter in­sight into the pa­tient’s over­all health and the qual­ity of care given at a hospi­tal.

Re­vamp­ing mea­sures

There is also a need for bet­ter re­port­ing and mea­sure­ment of so­cial con­di­tions that are out­side the hospi­tal’s con­trol. Mon­te­fiore Med­i­cal Cen­ter, a safety-net provider in New York, is ex­pected to be hit with a 1.26% penalty next year. About 85% of its pa­tient mix is Medi­care and Med­i­caid ben­e­fi­cia­ries.

Dr. Peter Shamamian, chief qual­ity of­fi­cer at Mon­te­fiore, said if the hospi­tal could re­port that a read­mis­sion oc­curred be­cause a pa­tient strug­gled to fol­low a care plan due to so­cial con­di­tions, it could avoid a penalty. “That is im­por­tant and it hits home for us,” he said. The CMS’ re­cent at­tempt at tak­ing such fac­tors into ac­count didn’t yield mean­ing­ful re­sults.

Still, the CMS in 2019 plans to be­gin ac­count­ing for pa­tients’ so­cio-eco­nomic sta­tus so the pro­gram is fairer for safety-net hos­pi­tals such as Mon­te­fiore and Yale. But ex­perts don’t think it’ll help much be­cause in­come is just one so­cial risk fac­tor, and the data on other fac­tors—such as if a pa­tient is frail or can’t drive—sim­ply don’t ex­ist in any stan­dard­ized way.

“We don’t have good mea­sures,” said Dr. Peter Pronovost, di­rec­tor of the Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins. A fed­eral agency should be tasked with look­ing at data met­rics so more progress can be made in de­vel­op­ing mea­sures.

Mea­sure­ments that ad­dress pa­tients’ well-be­ing could help move the dial on not only keep­ing pa­tients from com­ing back to the hospi­tal, but from need­ing to go in the first place. If a doc­tor knows be­fore pre­scrib­ing a med­i­ca­tion that the pa­tient doesn’t drive and won’t be able to get to the phar­macy, other in­ter­ven­tions can be put in place to help them, said Dr. Karen Joynt, an as­sis­tant pro­fes­sor of medicine at Washington Univer­sity School of Medicine. “How can we in­no­vate around so­cial risk and out­pa­tient needs that re­ally im­pact health?” she said. “The more money that gets put into value-based pay­ment, the more crit­i­cal it is that the met­rics are im­proved.”

Source: CMS and Mod­ern Health­care anal­y­sis

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