Post on 02-Jan-2016
Readmissions for Medicaid Patients: State-Level Benchmarks
and Initiatives AHRQ Annual Conference
September 10, 2012
David Kelley, M.D., M.P.A.
Office of Medical Assistance Programs
Pennsylvania Department of Public WelfareThe MMDLN is funded by an AHRQ contract to AcademyHealth. The funding supports in person meetings, Web conferences, and other activities that help the members use evidence-based research findings to make policy decisions. The views expressed in this document do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the fact that AHRQ is funding this group imply endorsement of any publications or policy statements that come out from the MMDLN.
Overview
Readmission Data Project Specifications for reporting and analysis Results
– Overall readmissions – Payment– MDC
State-specific report (sample) Conclusions
State Readmissions Policies
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Readmission Data Project Acknowledgements
18 states that contributed state-level summary data Tara Trudnak, Ph.D. and Gerry Fairbrother, Ph.D.,
AcademyHealth for analysis. Halley Brunsteter, Kevin Koenig, Jessica Teel and
Veronica Thomas at AcademyHealth for analysis assistance.
David Kelley, M.D. and Judy Zerzan, M.D. for leadership on the MMDLN readmissions workgroup and input to this analysis.
Katherine Griffith, M.H.S. at AcademyHealth for handling data submissions by individual states.
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Readmission Data ProjectPurpose
To provide an aggregate of 30-day readmission data from self-reporting State-level summary data
To compare differences in readmission rates by patient demographics, type of health plan and diagnosis
To assess level of variation among these States
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MethodsReadmission Specifications
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MethodsReadmission Specifications (cont.)
Calendar year of 2009 and 2010—extending backward and forward a 30-day window to capture associated index admissions and possible readmissions, respectively
– i.e., for 2010 data, if index admissions occurred in December of 2009 or readmissions occurred in January of 2011.
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MethodsReadmission Specifications (cont.)
Exclusions:– Dual eligible or those ≥ 65 yrs
NOT counted as a separate admission:– Transfer to another acute care hospital
– Transfer to another type of institution for inpatient care
– Interim billing (e.g., admitted as inpatient to the hospital, still patient)
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MethodsReporting Variables/Stratification
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Patient Demographics Age
– Newborn and Pediatric (0-20 yrs): <1, 1-12, 13-20– Adult (21-64 yrs): 21-44, 45-64
Gender– Female– Male
Race/ethnicity– White, Black, Hispanic, Asian/Pacific Island, Native
American, Other, Unknown
MethodsReporting Variables/Stratification (cont.)
Clinical Categories– Obstetric (OB) – Non-obstetric (non-OB)
Health Plan Types– FFS/PCCM, MCO
Physical Health (PH) and Behavioral Health (only analyzed PH)
Major Diagnostic Categories (MDC)
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Analysis
Focus on 30-day readmissions only
Aggregate of results of PH only for 18 participating States (4 States from 2009 and 14 States from 2010)
30-day readmission breakdown by each stratifying variable
Comparison of each State to the aggregate of 18 States (one-pagers will go to each State)
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ResultsOverall Readmissions
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Average 30-day Readmission Rates
MMDLNMedicaid patients,18 states(2010)
CMSMedicaid patients,45 states(2009)*
AHRQPrivate patients (2010)**
Total (age 0 to 64) 8.8% Total (age 1 to 64) 14.0% 8.6%
OB, regardless of age
3.3% OB, regardless of age
5.5% 3.4%
Non-OB pediatrics, age 0 - 20
5.7% Non-OB pediatrics, age 1 - 20
11.4% 8.2%
Non-OB adults, age 21 - 64
17.5% Non-OB adults, age 21 - 64
22.0% 10.4%
12*CMS (MSIS) for the Medicaid 2009 data.**AHRQ HCUP Nationwide Readmission Database 2010.
Results30-Day Readmission Rates by Clinical Categories and Population
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
22.0%
24.0%
Re
ad
mis
sio
n R
ate
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OB Pediatric OB Adult Non-OB Pediatric Non-OB Adult (0-20 yrs) (21-64 yrs) (0-20 yrs) (21-64 yrs)
Range(0.9%-6.2%)
Range(1.2%-6.4%)
Range(3.1%-14.0%)
Range(11.7%-21.5%)
ResultsAverage 30-day readmission rates by population
(physical health only)
Average 18 StatesPediatric Total (0-20 years) 5.3%Adult Total (21-64 years) 12.0%Adult Obstetric 3.4%Adult Non-Obstetric 17.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Rea
dm
issi
on
Rat
e
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Males Females 0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
10.6%
7.6%
Rea
dm
issi
on
Rat
e
ResultsAverage 30-day readmission rates by Gender
(physical health only)
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ResultsAverage 30-day readmission rates for by Age
(physical health only)
ResultsAverage 30-day Readmissions by Health Plan Type
(physical health only)
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ResultsOverall 30-day Readmission Rates for all 18
Participating States (physical health only)
11.8%11.3%11.2%
10.9%10.6%
10.1% 9.9% 9.6%
8.5% 8.3% 8.3% 8.1% 8.0%7.4% 7.4% 7.2%
5.8%5.5%
8.8%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
Re
ad
mis
sio
n R
ate
18
Participating States
ResultsReadmission Payment
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Readmissions Payment for 18 States
% Readmission Payment =
% Readmission Payment: 12.5%
Average Total Readmission Payment: 75.4 million
Total Readmission Payment: 1.4 billion
Payment for Readmissions Payment for Total Admissions
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ResultsAverage percent of 30-day readmission payment by
health plan (physical health only)
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ResultsAverage percent of 30-day readmission payment by
population (physical health only)
Pediatric Total 9.7%Adult Total 14%Adult Obstetric 3.9%Adult Non-Obstetric 16.9%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Pe
rce
nt
of
Re
da
dm
issi
on
Co
st
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Results30-Day Readmissions by
Major Diagnostic Categories
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ResultsTop 5 Diagnoses by Share of All 30-day Readmissions
All Ages (0-64yrs)
Category
Share of all Readmissions
(Category readmissions/Total
readmissions)
Share of Payment for Readmissions(Category payment for
readmissions/Total payment for readmissions)
Readmission Rate
(Category readmissions/ Category Admissions)
% Total Hospital Payment for
Readmissions(Category payment for readmissions/Category
payment for admissions)
1. Mental Disorders19.7% 12.6% 17.9% 15.9%
2. Complications of Pregnancy, Childbirth, & the Puerperium
11.7% 6.2% 4.2% 4.9%
3. Diseases of the Respiratory System
9.4% 11.6% 12.0% 15.4%
4. Diseases of the Digestive System
8.5% 9.0% 15.4% 16.8%
5. Diseases of the Circulatory System
8.0% 10.2% 17.2% 15.1%
17 Participating States
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ResultsTop 5 Diagnoses by Share of All 30-day
Readmissions for 0-12 yrs
Category Share of All
Readmissions
Share of Payment for
Readmissions
Readmission Rate
% Total Hospital Payment for
Readmissions
1. Diseases of the Respiratory System
21.3% 19.4% 6.9% 12.1%
2. Certain Conditions Originating in the Perinatal Period
17.1% 12.2% 30.7% 11.6%
3. Mental Disorders 9.1% 6.3% 11.2% 12.6%
4. Symptoms, Signs, & Ill-Defined Conditions
7.2% 5.9% 12.9% 22.6%
5. Injury & Poisoning 7.0% 8.2% 11.2% 13.7%
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9 Participating States
ResultsTop 5 Diagnoses by Share of All 30-day
Readmissions for 13-20 yrs
Category Share of All
Readmissions
Share of Payment for
Readmissions
Readmission Rate
% Total Hospital Payment for
Readmissions
1. Mental Disorders 32.6% 29.4% 12.0% 12.9%
2. Complications of Pregnancy, Childbirth & the Puerperium
30.9% 16.2% 4.2% 4.8%
3. Injury & Poisoning 6.4% 9.4% 11.5% 9.9%
4. Diseases of the Blood & Blood-Forming Organs
5.0% 6.5% 25.8% 27.9%
5. Diseases of the Digestive System
4.5% 5.8% 9.6% 11.3%
9 Participating States
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ResultsTop 5 Diagnoses by Share of All 30-day
Readmissions for 21-64 yrs
Category Share of All
Readmissions
Share of Payment
for Readmissions
Readmission Rate
% Total Hospital Payment for
Readmissions
1. Mental Disorders 20.0% 11.3% 23.9% 19.7%
2. Complications of Pregnancy, Childbirth & the Puerperium
12.7% 7.6% 4.2% 4.6%
3. Diseases of the Circulatory System
10.4% 14.4% 17.7% 14.9%
4. Diseases of the Digestive System
9.3% 10.5% 17.2% 17.5%
5. Diseases of the Respiratory System
8.4% 10.6% 17.4% 18.2%
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9 Participating States
State-specific Report
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Conclusions Overall, MCOs had the lowest
readmission rates
Non-Obstetric adults had the highest readmission rate
Readmission rates were highest among the 45-64 year old age groups
Readmission rates were higher for males than females
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Conclusions The diagnoses that contributed to the
highest share of readmissions:– All ages: Mental Disorders, Complications of
Pregnancy, Childbirth & the Puerperium– 0-12 yrs: Diseases of the Respiratory System and
Certain Conditions Originating in the Perinatal Period
– 13-20 yrs: Mental Disorders and Complications of Pregnancy, Childbirth & the Puerperium
– 20-64 yrs: Mental Disorders and Complications of Pregnancy, Childbirth & the Puerperium
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Conclusions
The diagnoses that contributed to the highest share of readmissions payment for all ages:– Mental Disorders – Diseases of the Respiratory System
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State Readmissions Policies
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Payment Policies
No payment for 24, 48, or 72 hour readmissions to same hospital.
No payment to hospitals for premature discharge that resulted in a readmissions within 7 or 14 days.
“A separate payment shall not be made for readmission to any hospital for the same diagnosis if the readmission occurs within 30 days of discharge, except for those cases where the department and QIO have given medical necessity approval.”
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Payment Policies
Readmissions are subject to postpayment review. MCO efficiency adjustment for readmissions within 30
days. MCO rate setting process whereby a percentage of premium payments for readmissions and preventable admissions are removed.
Inpatient services with a discharge and re-admission within 24 hours, for the same or related diagnosis, will be paid as one admission. In some instances payment may be made for both admissions, provided documentation supports both admissions.
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Other Policies or Programs
Case management– Within health plans– Embedded into practice
Transitions of care programs– STate Action on Avoidable
Rehospitalizations (STAAR)– ProjectRED– Discharge planning
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