Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives

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Slide 1

Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives

AHRQ Annual Conference
September 10, 2012

David Kelley, MD, MPA
Office of Medical Assistance Programs
Pennsylvania Department of Public Welfare

The Medicaid Medical Directors Learning Network (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.

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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, PhD, and Gerry Fairbrother, PhD, AcademyHealth for analysis.
• Halley Brunsteter, Kevin Koenig, Jessica Teel and Veronica Thomas at AcademyHealth for analysis assistance.
• David Kelley, MD, and Judy Zerzan, MD, for leadership on the MMDLN readmissions workgroup and input to this analysis.
• Katherine Griffith, MHS, at AcademyHealth for handling data submissions by individual states.

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Readmission Data Project

Purpose

• 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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Methods

Readmission Specifications

• Event-based rather than person-based.
  • Readmission Rate = # of readmissions / # total of hospital admissions.
  • Each admission is a new index admission and a potential readmissions if occurring with 7, 14, 0r 30 days after discharge of the previous admission.

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Methods

Readmission 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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Methods

Readmission 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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Methods

Reporting Variables/Stratification

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.

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Methods

Reporting 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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Results

Overall Readmissions

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Average 30-day Readmission Rates

*Centers for Medicare & Medicaid Services (CMS) Medicaid and Statistical Information System (MSIS) for the Medicaid 2009 data.
**AHRQ Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database 2010.

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Results

30-Day Readmission Rates by Clinical Categories and Population

Image: A graph shows the following readmission rates as ranges:

• OB Pediatric (0-20 years): Range(0.9% - 6.2%).
• OB Adult (21-64 years): Range(1.2% - 6.4%).
• Non-OB Pediatric (0-20 years): Range(3.1% - 14.0%).
• Non-OB Adult (21-64 years): Range(11.7% - 21.5%).

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Results

Average 30-day readmission rates by population (physical health only)

Image: A bar graph shows the readmission rate average for 18 States:

• Pediatric Total (0-20 years): 5.3%.
• Adult Total (21-64 years): 12.0%.
• Adult Obstetric: 3.4%.
• Adult Non- Obstetric: 17.5%.

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Results

Average 30-day readmission rates by Gender (physical health only)

Image: A bar graph compares the readmission rate for males and females:

• Males: 10.6%.
• Females: 7.6%.

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Results

Average 30-day readmission rates by Age (physical health only)

Image: A bar graph shows the readmission rate for the following age groups:

• Less than 1 year old: 3.4%.
• 1-12: 8.7%.
• 13-20: 7.0%.
• 21-44: 9.0%.
• 45-64: 17.7%.

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Results

Average 30-day Readmissions by Health Plan Type (physical health only)

Image: A bar graph shows the readmission rate for the following health plan types:

• Fee-for-service (FFS)/Impact of Primary Care Case Management (PCCM): 9.5%.
• Managed care organization (MCO): 7.7%.
• Total: 8.8%.

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Results

Overall 30-day Readmission Rates for all 18 Participating States (physical health only)

Image: A bar graph shows the readmission rates for the participating States. The average rate for the 18 States is 8.8%.

Results

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Results

Readmission Payment

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Readmissions Payment for 18 States

• % Readmission Payment = Payment for Readmissions / Payment for Total Admissions.
• % Readmission Payment: 12.5%.
• Average Total Readmission Payment: 75.4 million.
• Total Readmission Payment: 1.4 billion.

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Results

Average percent of 30-day readmission payment by health plan (physical health only)

Image: A bar graph shows the readmission rate for the following health plan types:

• FFS/PCCM: 13.1%.
• MCO: 11.0%.
• Total: 12.5%.

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Results

Average percent of 30-day readmission payment by population (physical health only)

Image: A bar graph shows the following readmission rates:

• Pediatric Total (0-20 years): 9.7%.
• Adult Total (21-64 years): 14%.
• Adult Obstetric: 3.8%.
• Adult Non-Obstetric: 16.9%.

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Results

30-Day Readmissions by Major Diagnostic Categories

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Results

Top 5 Diagnoses by Share of All 30-day Readmissions
All Ages (0-64yrs)

17 Participating States.

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Results

Top 5 Diagnoses by Share of All 30-day Readmissions
All Ages (0-64yrs)

9 Participating States.

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Results

Top 5 Diagnoses by Share of All 30-day Readmissions for 13-20 yrs

9 Participating States.

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Results

Top 5 Diagnoses by Share of All 30-day Readmissions for 21-64 yrs

9 Participating States.

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State-specific Report

Image: A sample State-specific report shows hospital readmissions statistics.

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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.