Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives AHRQ Annual Conference...

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%

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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%

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Males Females 0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

10.6%

7.6%

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ResultsAverage 30-day readmission rates by Gender


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ResultsAverage 30-day readmission rates for by Age


ResultsAverage 30-day Readmissions by Health Plan Type


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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%

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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%

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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


Readmissions


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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Readmissions

Share of Payment for

Readmissions

Readmission Rate


Readmissions


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%


4.5% 5.8% 9.6% 11.3%


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Readmissions

Share of Payment

for Readmissions

Readmission Rate


Readmissions


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%


9.3% 10.5% 17.2% 17.5%


8.4% 10.6% 17.4% 18.2%

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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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Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives AHRQ Annual Conference...

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