Getting a Gauge on Readmissions Penalties

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Northwestern_1345568661.jpg - Heart Failure at Northwestern Memorial Hospital
Robert A. Gordon, MD, a cardiologist at the Center for Heart Failure at Northwestern Memorial Hospital in Chicago, shares a congratulatory moment. The hospital implemented inpatient and outpatient strategies to improve outcomes and reduce readmission rates.
Source: Northwestern Memorial Hospital

In October, Medicare will begin tying payments to some of its performance measures. Hospitals that fare poorly on preventable readmissions for acute MI, heart failure and pneumonia may see reimbursement reduced by up to 1 percent in 2013. The penalty applies to all Medicare discharge payments during a fiscal year, and not just payments for preventable readmissions, making the financial loss potentially huge. Are you ready?

Nearly one in four Medicare beneficiaries admitted to a hospital with a diagnosis of heart failure (HF) between 2005 and 2008 was readmitted within 30 days (Circ Cardiovasc Qual Outcomes 2009;2[5]:407-413). There was wide variation across hospitals and regions, indicating a potential for improvement in performance and patient outcomes.

Readmissions also bear high costs. In 2008, the Medicare Payment Advisory Commission reported that Medicare spent $12 billion in 2005 on potentially preventable hospital readmissions, with HF readmissions contributing $903 million to the total. In an effort to curb these costs, the Patient Protection and Affordable Care Act (PPACA) established a hospital readmission reduction program that gave the Centers for Medicare & Medicaid Services (CMS) authority to penalize hospitals with greater than expected risk-adjusted readmission rates for HF, acute MI and pneumonia. Tracking is based on all-cause readmissions.

Beginning in fiscal year 2013, CMS may withhold up to 1 percent in inpatient Medicare payments to poor performers, increasing to 2 percent in 2014 and 3 percent in 2015. Also in 2015, CMS may expand the program to include chronic pulmonary obstructive disease, CABG, PCI and other vascular conditions. “For hospitals with high Medicare service volume, and a high preventable readmissions rate, the aggregate effect of the penalty could be considerable,” the Congressional Research Service wrote in the 2010 report, “Medicare Hospital Readmissions: Issues, Policy Options and the PPACA.”

Measuring up
The American College of Cardiology (ACC) and the American Heart Association (AHA) published performance measures for HF in 2005 to provide physicians with evidence-based guidelines defining practices that facilitate optimal patient care. With acute MI, there is strong evidence that high performance based on guideline recommendations improves outcomes, says Robert O. Bonow, MD, co-chair of the writing committee for the HF performance measures, which were updated in 2011. But with HF, whether hospitals comply with the recommended measures, or if compliance leads to improved outcomes, is less clear.

“In acute MI, [with compliance] you have lower mortality and recurrent events,” says Bonow, director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine in Chicago. “With heart failure, it is much more tricky because the connection between high performance among those processes of care—giving the right drugs, discharge instructions and so forth—and tying those to either a reduction in mortality or, most importantly, 30-day readmissions, that connection has been lacking.”

David W. Schopfer, MD, a cardiologist at the San Francisco Veterans Affairs Medical Center, and colleagues tried to clarify the connection by evaluating compliance among 3,655 hospitals identified through CMS’ Hospital Compare open-access database that admitted patients with HF diagnoses in 2008 (Am Heart J 2012;164[1]:80-86). For their analysis, they focused on four of the 2005 measures: evaluation of left ventricular systolic function; administration of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs); providing smoking cessation counseling; and giving discharge instructions.

They found that socioeconomic status and hospital volume were stronger predictors of 30-day mortality and readmission rates than compliance, while only evaluation of left ventricular systolic function and smoking cessation counseling were associated with lower HF readmission rates.

“Hospitals need to focus on strategies beyond compliance,” says Schopfer, citing as an example his medical center’s protocol to contact the patient within 48 hours after discharge to ask about his or her status, review medications and answer any questions. “It is an opportunity to clarify in case there is a problem.”

But many hospitals may not implement such strategies. In a study designed to define the range and prevalence of recommended practices for reducing 30-day readmissions