CMS Inpatient Rule Hammers 'Excessive' Readmissions, Ups Hospital Payments

Hospitalists are ramping up quality improvement initiatives that they hope will decrease readmission rates by October 2012, when pay cuts from revisions of Medicare’s inpatient prospective payment system start to take effect.

The Center for Medicare and Medicaid Services’ final rule to update the payment system rates for hospitals beginning Oct. 1 will increase overall payments to hospitals by 1.1%, but also will begin implementing policies that ultimately will cut hospital reimbursement if patients are readmitted in fewer than 30 days.

"We see preventable readmissions, but we also see a whole large group of nonpreventable readmissions," said Dr. Lauren Doctoroff, a hospitalist at Beth Israel Deaconess Medical Center, Boston. "What the payment system is trying to do is measure all-cause readmissions, and this makes most hospitalists nervous."

The final Medicare Inpatient Prospective Payment System rule estimates that total payments to acute care hospitals for inpatient services occurring in fiscal year 2012 (which begins Oct. 1) will increase by about $1.1 billion to total approximately $100 billion. Each year, the rule spells out recalculated payments for individual codes, leading to a mixed bag of increases and decreases for specific procedures.

This year, the CMS rule also expanded the Hospital Inpatient Quality Reporting Program, with a greater focus on patient outcomes and experiences. The agency added a reporting measure involving the rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, along with reporting measures for stroke and venous thromboembolism.

However, the agency said that it is not adopting its prior proposal to add contrast-induced acute kidney injury to the list of hospital-acquired conditions that are not eligible for Medicare payments. In an interview, Dr. Doctoroff welcomed that news, saying "it’s a condition that’s hard to prevent."

But for hospitalists, the most important provisions in the new rule are those asking hospitals to begin measuring readmission rates for three conditions (acute myocardial infarction, heart failure, and pneumonia) in preparation for Medicare to begin cutting reimbursement for "excessive" all-cause readmission rates. The rule also outlines a methodology to calculate those excessive readmission rates.

CMS defines readmission as "occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization."

CMS has set 30 days as the time period it will use to determine if a patient was readmitted unnecessarily. Beginning in 2012, it will begin cutting overall payments for hospitals that have numbers the agency deems excessive.

"As many as one in three Medicare patients who leave the hospital will be readmitted within 30 days of discharge," the agency said in a statement. "A large portion of these readmissions can be avoided through well-coordinated, high-quality hospital care."

Dr. Doctoroff noted that hospitalists and the Society for Hospital Medicine have been working for several years to decrease readmissions in an effort to improve patient care.

The society, where Dr. Doctoroff sits on the Public Policy Committee, initiated Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), which works to help hospitalists to identify high-risk patients upon discharge and to facilitate information flow between inpatient and outpatient providers.

Project BOOST mentor sites now number more than 60, and the group wants to see 100 sites by the end of 2011. Early data from six sites show readmission rates falling from 14.2% to 11.2%, and those six sites also saw a 21% reduction in 30-day all-cause readmission rates, according to the society.

At Beth Israel, the entire group of more than 40 hospitalists has focused on how to improve communication and transition of care to primary care physicians, Dr. Doctoroff said.

For example, the hospitalists are trying to provide continuity of care by working with home health agencies on improved communications once a patient leaves the hospital, Dr. Doctoroff said. In addition, "we’ve put in place easier ways to set up posthospitalization appointments" using an administrative service that can contact patients, she said.

Finally, Beth Israel’s hospitalists have set up a postdischarge clinic in the hospital’s primary care facility where patients can receive follow-up care immediately following their discharge from the hospital.

All of these measures "improve the likelihood that the patient gets back to their primary care clinic," she said. "It also gives me and the other hospitalists an interesting view on outpatient medicine."

Still, it’s not possible to prevent all readmissions, Dr. Doctoroff said. "Our hospital is one of the high-readmission hospitals," she said, and could be looking at reductions in payments in October 2012 as a result of this new rule, unless hospitalists and other hospital staff can bring readmissions down.

Decreasing readmissions represents "such a multifactorial problem," she said. "There’s a group of patients it’s possible to keep out of the hospital completely. But there’s another group where, if you can stretch [readmissions] out to every 6 weeks instead of every month, you’re improving."

To improve care and prevent payment cuts relating to that second group of patients, hospitals may need to implement strategies aimed at delaying, rather than preventing, readmission, Dr. Doctoroff said. Those patients also tend to fall lower on the socioeconomic scale, but the new Medicare rules don’t account for socioeconomic status, she said, adding, "I worry very much about the safety-net hospitals."

Hospitalists are ramping up quality improvement initiatives that they hope will decrease readmission rates by October 2012, when pay cuts from revisions of Medicare’s inpatient prospective payment system start to take effect.

The Center for Medicare and Medicaid Services’ final rule to update the payment system rates for hospitals beginning Oct. 1 will increase overall payments to hospitals by 1.1%, but also will begin implementing policies that ultimately will cut hospital reimbursement if patients are readmitted in fewer than 30 days.

"We see preventable readmissions, but we also see a whole large group of nonpreventable readmissions," said Dr. Lauren Doctoroff, a hospitalist at Beth Israel Deaconess Medical Center, Boston. "What the payment system is trying to do is measure all-cause readmissions, and this makes most hospitalists nervous."

The final Medicare Inpatient Prospective Payment System rule estimates that total payments to acute care hospitals for inpatient services occurring in fiscal year 2012 (which begins Oct. 1) will increase by about $1.1 billion to total approximately $100 billion. Each year, the rule spells out recalculated payments for individual codes, leading to a mixed bag of increases and decreases for specific procedures.

This year, the CMS rule also expanded the Hospital Inpatient Quality Reporting Program, with a greater focus on patient outcomes and experiences. The agency added a reporting measure involving the rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, along with reporting measures for stroke and venous thromboembolism.

However, the agency said that it is not adopting its prior proposal to add contrast-induced acute kidney injury to the list of hospital-acquired conditions that are not eligible for Medicare payments. In an interview, Dr. Doctoroff welcomed that news, saying "it’s a condition that’s hard to prevent."

But for hospitalists, the most important provisions in the new rule are those asking hospitals to begin measuring readmission rates for three conditions (acute myocardial infarction, heart failure, and pneumonia) in preparation for Medicare to begin cutting reimbursement for "excessive" all-cause readmission rates. The rule also outlines a methodology to calculate those excessive readmission rates.

CMS defines readmission as "occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization."

CMS has set 30 days as the time period it will use to determine if a patient was readmitted unnecessarily. Beginning in 2012, it will begin cutting overall payments for hospitals that have numbers the agency deems excessive.

"As many as one in three Medicare patients who leave the hospital will be readmitted within 30 days of discharge," the agency said in a statement. "A large portion of these readmissions can be avoided through well-coordinated, high-quality hospital care."

Dr. Doctoroff noted that hospitalists and the Society for Hospital Medicine have been working for several years to decrease readmissions in an effort to improve patient care.

The society, where Dr. Doctoroff sits on the Public Policy Committee, initiated Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), which works to help hospitalists to identify high-risk patients upon discharge and to facilitate information flow between inpatient and outpatient providers.

Project BOOST mentor sites now number more than 60, and the group wants to see 100 sites by the end of 2011. Early data from six sites show readmission rates falling from 14.2% to 11.2%, and those six sites also saw a 21% reduction in 30-day all-cause readmission rates, according to the society.

At Beth Israel, the entire group of more than 40 hospitalists has focused on how to improve communication and transition of care to primary care physicians, Dr. Doctoroff said.

For example, the hospitalists are trying to provide continuity of care by working with home health agencies on improved communications once a patient leaves the hospital, Dr. Doctoroff said. In addition, "we’ve put in place easier ways to set up posthospitalization appointments" using an administrative service that can contact patients, she said.

Finally, Beth Israel’s hospitalists have set up a postdischarge clinic in the hospital’s primary care facility where patients can receive follow-up care immediately following their discharge from the hospital.

All of these measures "improve the likelihood that the patient gets back to their primary care clinic," she said. "It also gives me and the other hospitalists an interesting view on outpatient medicine."

Still, it’s not possible to prevent all readmissions, Dr. Doctoroff said. "Our hospital is one of the high-readmission hospitals," she said, and could be looking at reductions in payments in October 2012 as a result of this new rule, unless hospitalists and other hospital staff can bring readmissions down.

Decreasing readmissions represents "such a multifactorial problem," she said. "There’s a group of patients it’s possible to keep out of the hospital completely. But there’s another group where, if you can stretch [readmissions] out to every 6 weeks instead of every month, you’re improving."

To improve care and prevent payment cuts relating to that second group of patients, hospitals may need to implement strategies aimed at delaying, rather than preventing, readmission, Dr. Doctoroff said. Those patients also tend to fall lower on the socioeconomic scale, but the new Medicare rules don’t account for socioeconomic status, she said, adding, "I worry very much about the safety-net hospitals."

Hospitalists are ramping up quality improvement initiatives that they hope will decrease readmission rates by October 2012, when pay cuts from revisions of Medicare’s inpatient prospective payment system start to take effect.

The Center for Medicare and Medicaid Services’ final rule to update the payment system rates for hospitals beginning Oct. 1 will increase overall payments to hospitals by 1.1%, but also will begin implementing policies that ultimately will cut hospital reimbursement if patients are readmitted in fewer than 30 days.

"We see preventable readmissions, but we also see a whole large group of nonpreventable readmissions," said Dr. Lauren Doctoroff, a hospitalist at Beth Israel Deaconess Medical Center, Boston. "What the payment system is trying to do is measure all-cause readmissions, and this makes most hospitalists nervous."

The final Medicare Inpatient Prospective Payment System rule estimates that total payments to acute care hospitals for inpatient services occurring in fiscal year 2012 (which begins Oct. 1) will increase by about $1.1 billion to total approximately $100 billion. Each year, the rule spells out recalculated payments for individual codes, leading to a mixed bag of increases and decreases for specific procedures.

This year, the CMS rule also expanded the Hospital Inpatient Quality Reporting Program, with a greater focus on patient outcomes and experiences. The agency added a reporting measure involving the rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, along with reporting measures for stroke and venous thromboembolism.

However, the agency said that it is not adopting its prior proposal to add contrast-induced acute kidney injury to the list of hospital-acquired conditions that are not eligible for Medicare payments. In an interview, Dr. Doctoroff welcomed that news, saying "it’s a condition that’s hard to prevent."

But for hospitalists, the most important provisions in the new rule are those asking hospitals to begin measuring readmission rates for three conditions (acute myocardial infarction, heart failure, and pneumonia) in preparation for Medicare to begin cutting reimbursement for "excessive" all-cause readmission rates. The rule also outlines a methodology to calculate those excessive readmission rates.

CMS defines readmission as "occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization."

CMS has set 30 days as the time period it will use to determine if a patient was readmitted unnecessarily. Beginning in 2012, it will begin cutting overall payments for hospitals that have numbers the agency deems excessive.

"As many as one in three Medicare patients who leave the hospital will be readmitted within 30 days of discharge," the agency said in a statement. "A large portion of these readmissions can be avoided through well-coordinated, high-quality hospital care."

Dr. Doctoroff noted that hospitalists and the Society for Hospital Medicine have been working for several years to decrease readmissions in an effort to improve patient care.

The society, where Dr. Doctoroff sits on the Public Policy Committee, initiated Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), which works to help hospitalists to identify high-risk patients upon discharge and to facilitate information flow between inpatient and outpatient providers.

Project BOOST mentor sites now number more than 60, and the group wants to see 100 sites by the end of 2011. Early data from six sites show readmission rates falling from 14.2% to 11.2%, and those six sites also saw a 21% reduction in 30-day all-cause readmission rates, according to the society.

At Beth Israel, the entire group of more than 40 hospitalists has focused on how to improve communication and transition of care to primary care physicians, Dr. Doctoroff said.

For example, the hospitalists are trying to provide continuity of care by working with home health agencies on improved communications once a patient leaves the hospital, Dr. Doctoroff said. In addition, "we’ve put in place easier ways to set up posthospitalization appointments" using an administrative service that can contact patients, she said.

Finally, Beth Israel’s hospitalists have set up a postdischarge clinic in the hospital’s primary care facility where patients can receive follow-up care immediately following their discharge from the hospital.

All of these measures "improve the likelihood that the patient gets back to their primary care clinic," she said. "It also gives me and the other hospitalists an interesting view on outpatient medicine."

Still, it’s not possible to prevent all readmissions, Dr. Doctoroff said. "Our hospital is one of the high-readmission hospitals," she said, and could be looking at reductions in payments in October 2012 as a result of this new rule, unless hospitalists and other hospital staff can bring readmissions down.

Decreasing readmissions represents "such a multifactorial problem," she said. "There’s a group of patients it’s possible to keep out of the hospital completely. But there’s another group where, if you can stretch [readmissions] out to every 6 weeks instead of every month, you’re improving."

To improve care and prevent payment cuts relating to that second group of patients, hospitals may need to implement strategies aimed at delaying, rather than preventing, readmission, Dr. Doctoroff said. Those patients also tend to fall lower on the socioeconomic scale, but the new Medicare rules don’t account for socioeconomic status, she said, adding, "I worry very much about the safety-net hospitals."