Source: Commonwealth Fund, 2010 Medicare Readmission Rates 2009
Medicare readmission data revealed that Illinois ranked #48 for
Heart Failure, #47 for Heart Attack, and #43 for Pneumonia.
Slide 4
CMS Readmissions Independent payment reduction program Goal 20%
reduction by 2014 Penalizes excess readmissions ACA: exclude
unrelated, planned Uses AMI, CHF, Pneumonia diagnostic categories
as index admissions (w/more to come) Imposes a 1% cap of total
Medicare payments in 2013, 2% - 2014, 3% - 2015 & thereafter
Select hospitals not yet CAH, LTC, Rehab or Childrens Excludes case
volumes < 25 4
Slide 5
Illinois Readmission Activity Projected Medicare estimates:
2010 = $30.3 M 2011 = $25.3 M Improvement in 2012 - $20.2 M 128
Hospitals (CMS data 2008-11) 12.5% No Penalty 72.7% Some Penalty
14.8% Maximum Penalty Nationally: (34.5%) (57.4%) ( 8.3%)
Slide 6
Key Initiatives Improving transitions of care Developing &
improving palliative care Redesigning hospital discharge processes
Strengthening hospitalist programs Measuring reductions in
readmissions using standardized metrics
Slide 7
Illinois Readmission Profile Activity across Illinois hospitals
Unique Patient Identifier Hospital agreements & submission 3Ms
APR-DRG software readmission chains for clinically-related causes
All payer hospital-specific & aggregate reports
Slide 8
Illinois SMART ACT - Readmissions HFS Performance-based System
for PPR HFS seeks a $40M savings in FY2013 Uses 3Ms PPR software
& APR-DRGs as foundation Hospitals to be individually compared
against a target PPR rate threshold using 2010 data Above threshold
pymt w/hold Below threshold no pymt w/hold 8
Slide 9
Summary Comparison IHA HFS Medicare Primary Focus Quality
Improvement $40 M Budget Savings Reimbursement Penalty for
Non-compliance Patient Population All payers/Acute care inpatients;
OBV, ED Medicaid beneficiaries - inpatients Medicare beneficiaries
- inpatients Readmission criteria Clinically-related cause: 7 &
30 days Clinically-related cause: 30 days All cause for readm w/in
30 days of index d/c for AMI, CHF or Pneumonia Readmission Method
Chain Yes/No Data Timeframe Starts w/2011 1 -3 Q and then quarterly
FY 2010 CMS Hospital Compare - 3yrs rolling (7/1/08 - 6/30/11)
9
Using IL Resource for Quality Improvement & Culture
Transformation 11
Slide 12
Potential Preventable Readmission (PPR) A readmission that is
clinically related to the index hospitalization. 12
Slide 13
Readmission Chain A sequence of PPRs that are all clinically
related to the index hospitalization. May contain an index
hospitalization and 1 PPR (most common), or may contain index and
multiple PPRs. 13
Slide 14
3M Potential Preventable Readmissions (PPR) Methodology
Exclude: Newborns Obstetrical Major metastatic malignancy Other
malignancy HIV Trauma Burn Left against medical advice 14
Slide 15
Readmission Example #1 Patient admitted on 4/1 (Day 1),
discharged on 4/5 (Day 5) w/diagnosis of CHF, subsequently
readmitted with same diagnosis on 4/29 & d/c on 5/8 15
IHAHFSCMS Index d/c date D/C diagnosis 4/5 CHF 4/5 CHF 4/5 CHF
Readmission CHF Yes - Clinically related Yes -within 30 days of
index d/c w/CHF Equals1 Chain 1 Readmission Paymt
PenaltyN/AApplies
Slide 16
Readmission Example #2 Patient admitted on 4/1 (Day 1),
discharged on 4/5 (Day 5) w/diagnosis of Pneum, subsequently
readmitted with Hip Replacement on 4/29 & d/c on 5/3 16
IHAHFSCMS Index d/c date D/C diagnosis 4/5 Pneu 4/5 Pneu 4/5 Pneu
Readmission Hip Replacement No - Not Clinically related Yes - index
d/c re: Pneu and readm within 30 days Equals0 Chain 1 Readmission
Paymt PenaltyN/ANoneApplies
Slide 17
Readmission Example #3 Patient admitted on 4/1 (Day 1),
discharged on 4/5 (Day 5) w/diagnosis of Hip Replacement,
subsequently readmitted with CHF on 4/29 & d/c on 5/8 17
IHAHFSCMS Index d/c date D/C diagnosis 4/5 Hip Replacement 4/5 Hip
Replacement 4/5 Hip Replacement ReadmissionNo - Not Clinically
related No - index d/c not 1 of 3 diagnosis Equals0 Chain 0
Readmission Paymt PenaltyN/ANone
Slide 18
Readmission Example #4 Patient admitted on 4/1 (Day 1),
discharged on 4/5 (Day 5) w/diagnosis of Hip Replacement,
subsequently readmitted with CHF on 4/29 & d/c on 5/8 &
readmitted w/CHF on 5/15, d/c on 5/28 18 IHAHFSCMS Index d/c date
D/C diagnosis 4/5 Hip Replacement 4/5 Hip Replacement 4/5 Hip
Replacement Readmission (CHF) 5/15 No unrelated Yes No unrelated
Yes No not 1/3 cond Yes for cause 30 days re: CHF index Equals 0
Chain/ 1 Chain 0 Chain/ 1 Chain1 Readmission Paymt
PenaltyN/ANone/Applies
Slide 19
Key Considerations IHA/HFS What is d/c date? What is d/c
diagnosis? Any readmission activity w/in 30 days of d/c? Is
readmission diagnosis clinically related? If so, a chain begins and
WILL continue unless broken by: Any non-related readmission within
30 days Time interval > than 30 days Any PPR exclusion activity
19
Slide 20
Key Considerations CMS What is d/c date? What is d/c diagnosis?
Is the d/c diagnosis 1 of 3 AMI, CHF or Pneumonia? AND Any
readmission activity w/in 30 days of d/c? If so, then meets YES
criteria Readmission penalty will be applied 20
Slide 21
Illinois Readmission Reports Hospital Level Reports (9) Service
line Index APR DRG Point of Origin Discharge status Principal Payer
Top readmission APR DRGs Claim level ED/OC Encounters 21
Next Steps Cultural Opportunities Assessment Communication
CMS/IHA; HFS; Patient & Family Advisory; Committees:
Quality/Medical Records/Medical Staff/Nurse Staff/Senior Leadership
External partners Education & Training: Training recorded,
future webinars, site visits Initial Target & Proposed Action
Plan 32
Slide 33
Future Institute Activities Suggested topics Specialty
Hospitals Across Hospital Activity Provider Possibilities Enhancing
Cultural Gains 33
Slide 34
Additional Support Contact COMPDATACOMPDATA Includes recorded
webinar training Email: [email protected]@ihastaff.org
Phone: 866/262-6222 HFS Medicaid Readmission PolicyReadmission SAVE
the DATE: October 3 (Wed) 12 1pm 34
