Collaborative on Reducing Readmissions

in Florida

May 2011

Overview of Call

1. Overview of Readmission Trends

2. Update on Collaborative Projects

3. CMS Readmission Reduction Program

4. Partnership for Patients

5. Next Steps

Congestive Heart FailureGoal <8.0%

Readmissions within 15 Days ~ All Readmissions

3

Acute Myocardial InfarctionGoal <6.5%

Readmissions within 15 Days ~ All Readmissions

4

PneumoniaGoal <4.0%

Readmissions within 15 Days ~ All Readmissions

5

CABGGoal <8.0%

Readmissions within 15 Days ~ All Readmissions

6

Hip ReplacementGoal <2.5%

Readmissions within 15 Days ~ All Readmissions

7

Update on Projects: Standardized Discharge Form

• Working with FADONA, FMDA, AHCA, CARES• 3 rounds of testing• 7th version of form• Two pages, designed to capture critical

information about patient• Finalizing instructions and roll-out approach• Statewide testing next• Will replace 3008

FOS-FHA Hip Readmission Project

• Began Sept 2010

• Improving understanding of why hip replacement patients are readmitted– AHCA data– Case reviews

• Explore statewide initiatives

Hospital-Health Plan Initiatives

• Aetna, AvMed, BCBSFL, CIGNA, Health First, Humana & United

• Agreement on standard measure(s) and risk adjustment

• Sharing information on at risk patients• Hospital-Health Plan case manager outreach • Inventory of readmission programs underway at

hospital and health plans

PPACA Directives Related to Readmissions

• Reduce payments for hospitals with high readmission rates

• High volume/expenditure, endorsed by an entity under contract with CMS, excludes readmissions unrelated to the prior discharge

• FY 2013 payments, 3 conditions, expand following year

• Include an all-condition measure• Time frame consistent with endorsed measure• Public reporting of rates• All patient readmission rates

FY 2012 IPPS/LTCH PPS Proposed Rule

• Selection of applicable conditions• Definition of readmission • Measures and Methodology for calculating

excess readmission– Index hospitalization– Risk adjustment– Risk standardized readmission rate– Data sources– Exclusion of certain readmissions

• Public reporting of readmissions• Applicable period

FY2013 IPPS/LTCH PPS Proposed Rule

• Base operating DRG payment amount

• Adjustment factor (ratio & floor)

• Aggregate payments for excess readmissions

• Applicable hospital

General

• Definition: “a readmission is when a patient is discharged from the applicable hospital to a nonacute setting and then is readmitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization”

• Counts as one readmission regardless of how many readmissions within the period

• Time period: 30 days after discharge from index admission

• Data Source: Medicare FFS data, minimum of 25 cases

Selection of Conditions/Measures

• AMI, heart failure, pneumonia– High volume, high expenditure criteria– Endorsed by an entity under contract– Exclusions for readmissions unrelated to prior

discharge

• Measures– AMI 30-day Risk Standardized Readmission Measure

(NQF # 0505)– Heart Failure 30-day Risk Standardized Readmission

Measure (NQF# 0330)– Pneumonia 30-day Risk Standardized Readmission

Measure (NQF#0506)

Exclusions for Unrelated Readmissions

• General– Transfers to another acute care hospital– In-hospital deaths– Patients leaving Medicare FFS within 30 days post-

discharge – Discharged against medical advice

• AMI– Excludes those readmissions when PTCA or CABG

unless principal dx for readmission is Heart failure, AMI, Unstable angina, Arrhythmia, Cardiac arrest

• Heart Failure/Pneumonia– None

Measures

• Except with AMI, includes readmissions for all causes, without regard to the principal dx of the readmission– Patient perspective– Prevents gaming– No clinically sound strategies for identifying

readmissions unrelated to hospital quality based on document cause of readmission

Risk adjustment

• Patient risk factors (patient demographics, co-existing medical conditions, indicators of patient frailty) identified from inpatient & outpatient

claims for 12 months prior to hospitalization

• Calculates a hospital risk standardized readmission ratio

• If no claims in prior 12 months, only co-morbidities from the index admission will be used

Time Window

• 30 days– Clinically meaningful to collaborate with

medical communities to reduce readmission risk

– Accepted standard in research & measurement

– Motivates hospital & community partners to work together

• Ready to be discharge• Improves communication across providers• Reduces risk of infection• Educating patients on symptoms to monitor• Where to seek follo up care

Applicable Time Period

• Hospital Compare uses 3 years of data

• Proposing to use July 1, 2008 through June 30, 2011 to calculate excess readmission rates

• Conducting analyses to look at using longer or shorter data periods

Other Provisions

• Must publicly report the hospital specific data from the readmission reduction program

• Calculation of all patient readmission rate– Hospitals or state or other entity will have to submit the

data

• Excess readmission methodologyRisk adjusted actual readmissions

Risk adjusted expected readmissions

Medicare Spending Per Beneficiary

• CMS required to include “efficiency” measure in VBP for FY 2014

• Hospital specific measure • Part A & Part B spending• 3 days before admission – 90 days post

discharge• Baseline period: May 15, 2010 though Feb 14,

2011 • Measure: May 15, 2012 – Feb 14, 2013

CMS Partnership for Patients

1. Reduce harm caused to patients in hospitals. By end of 2013, reduce preventable HACs by 40% from 2010.

2. Improve care transitions. By end of 2013, decrease preventable complications during a transition from one care setting to another, resulting in a 20% reduction in readmissions.

Community-Based Care Transition Program

• $500 million• Accepting applications

– Hospitals with high readmission rates, partnering with CBO

– CBOs providing care transition services– Must demonstrate reduced 30 day all-cause

readmission rates

• 10th Scope of Work – Assistance from QIO

• www.healthcare.gov/center/programs/partnership/join/index.html

Discussion

1. Have you reviewed the NQF measures for readmission?

2. Do you believe they adequately exclude for planned or unrelated readmissions? 

3. What time window do you think is appropriate to measure the hospital’s performance on reducing readmissions? 

4. Time period for measurement:  how much data do you think is adequate to measure readmission rates?

5. Where should CMS get all payer data? 

6. Are you interested in applying for a Care Transitions grant?

7. How actively are you following the IPPS rule?

8. Is your hospital assessing the proposed rule and incorporating estimated impacts into the budget?

Next Steps

• Workgroups will continue

• Statewide partnership on Readmissions

• Monthly calls/meetings to share best practices