Time to Raise the Bar on Preventable Hospital Readmissions?

A new report suggests that hospitals can have the greatest impact on reducing preventable readmissions within seven days of discharge and not through the 30-day mark at which they are currently judged by Medicare.

According to a study published in the Annals of Internal Medicine,

Early readmissions were more likely to be preventable and amenable to hospital-based interventions.  Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.

The study, conducted at 10 academic medical centers and involving more than 800 of their patients who had been readmitted to the hospital, concludes that readmissions within seven days may more accurately reflect the quality of care hospitals provide than the 30-day measure applied by Medicare’s hospital readmissions reduction program.

To learn more about the report, its findings, and their implications, go here, to the web site of the Annals of Internal Medicine, to see the study “Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.”

CMS Proposes Regulatory Changes in Medicare Quality Programs

Last week the Centers for Medicare & Medicaid Services published a proposal detailing how it envisions paying for Medicare services in FY 2019 under its inpatient prospective payment system.

On Tuesday this space features a summary of the proposed changes in inpatient rates, Medicare disproportionate share payments (Medicare DSH) and how they would be calculated, and proposed changes in the Medicare area wage index system.  Yesterday we looked at proposed changes in regulations governing multi-campus hospitals, Medicare and Medicaid electronic health record incentive programs, and the hospital readmissions reduction program.

Today we describe proposed changes in various Medicare quality efforts.

Value-Based Purchasing Program

 CMS proposes removing ten measures from its value-based purchasing program, all of which are already included in other Medicare reporting requirements:  all seven health care-associated infection and patient safety measures and three condition-specific payment measures.  See the CMS fact sheet for a list of the specific measures and the rationale for their removal.

 Hospital Inpatient Quality Reporting Program

 CMS proposes removing certain measures from the hospital inpatient quality reporting program while retaining those same measures in one of its other value-based purchasing programs.  CMS is focusing on measures that provide opportunities to reduce both paperwork and reporting burden on providers and patient-centered outcome measures rather than process measures.  See the CMS fact sheet for specific information about a measure to be added, 18 to be removed, and 21 that will be extracted from the data hospitals report for other programs.

Electronic Clinical Quality Measures

For 2019, CMS proposes that hospitals report on only four self-selected measures (of the current 16 measures) only for a self-selected quarter of the calendar year.  It also proposes that the submission period for the EHR incentive program be the two months following the end of the calendar year.  Finally, it proposes eliminating eight of the 16 clinical quality measures starting with the 2020 reporting year.  See the CMS fact sheet for further information.

Price Transparency

A major theme of this year’s proposed rule is increasing the transparency of hospital charges.  Under current law, hospitals are required to establish and make public a list of their standard charges.  To encourage price transparency by improving public access to charge information, CMS proposes updating its guidelines to specifically require hospitals to make public a list of their standard charges on the Internet.

Request for Information Regarding Price Transparency

 CMS believes patients face challenges because of insufficient price transparency, including patients being surprised by out-of-network bills for physicians who provide services at in-network hospitals and patients being surprised by facility fees and physician fees for emergency room visits.  For this reason, it is seeking feedback from the public regarding how CMS should define what are standard charges; about what kind of pricing information the public would find useful; about whether hospitals should be required to disclose what Medicare pays them for individual services; and about how CMS should enforce whatever transparency standards it ultimately adopts.

*          *          *

You also can learn more by reviewing the entire proposed 1883-page rule here or reading the CMS fact sheet here.

 

CMS Proposes Regulatory Changes in EHR Incentive and Readmissions Reduction Programs

Last week the Centers for Medicare & Medicaid Services published a proposal detailing how it envisions paying for Medicare services in FY 2019 under its inpatient prospective payment system.

Yesterday this space featured a summary of the proposed changes in inpatient rates, Medicare disproportionate share payments (Medicare DSH) and how they would be calculated, and proposed changes in the Medicare area wage index system.

Today we look at proposed changes in regulations governing multi-campus hospitals, Medicare and Medicaid electronic health record incentive programs, and the hospital readmissions reduction program.

Recognizing Multi-Campus Hospitals

Recognizing the considerable consolidation taking place in the hospital industry, CMS proposes several new regulations outlining how multi-campus hospitals can demonstrate that they satisfy the criteria for being a Rural Referral Center or a Sole-Community Hospital.  In general, the proposed regulations attempt to treat the hospitals as a single entity but address specific circumstances unique to multi-campus hospitals that currently are either ambiguous or wholly unaddressed in existing regulations.  CMS notes that these new regulations would constitute a change in the conditions under which an application would approved for existing multi-campus hospitals already deemed as meeting Rural Referral Center or Sole-Community Hospital criteria and that these hospitals have a responsibility to notify CMS if they no longer qualify for such status.

Medicare and Medicaid EHR Incentive Programs

CMS proposes overhauling its Medicare and Medicaid electronic health record (EHR) incentive programs, frequently referred to as “meaningful use,” to make them more flexible and less burdensome; to emphasize measures that require the exchange of health information between providers and patients; and to give providers incentives to make it easier for patients to obtain their medical records electronically.  In the proposed rule, CMS calls for changes in the EHR incentive program to promote greater interoperability and to make the EHR incentive program more flexible and less burdensome by placing a strong emphasis on measures that require the exchange of health information between providers and patients.

With this in mind, CMS has renamed its meaningful use program “Promoting Interoperability.”  As part of this updated program, it requires providers to use the 2015 edition of certified electronic health record technology in 2019 to demonstrate meaningful use, qualify for incentive payments, and avoid reductions of Medicare payments.  CMS also proposes eliminating 25 total reporting measures across the five programs.  See the CMS fact sheet for specific information.

Promoting Interoperability Request for Information

In the proposed rule, CMS includes a request for information to obtain feedback from stakeholders on solutions to better achieve interoperability or the sharing of health care data between providers.  Specifically, it requests feedback on the possibility of revising conditions of participation related to interoperability as a way to increase electronic sharing of data by hospitals.

Medicare Hospital Readmissions Reduction Program

The 21st Century Cures Act requires that CMS begin assessing hospital readmission performance by comparing hospitals’ performance to that of similar hospitals, with “similar” to be based on the proportion of dual-eligible Medicare-Medicaid patients they serve.  As proposed last year, CMS will assign eligible hospitals into five equal-sized peer groups based on their proportion of dual-eligible patients.  This is the first year this approach will be employed.  The measures to be used in the program will remain the same.

*          *          *

Tomorrow we will look at the Medicare value-based purchasing program, the hospital inpatient quality reporting program, electronic clinical quality measures, and price transparency.

You also can learn more by reviewing the entire proposed 1883-page rule here or reading the CMS fact sheet here.

 

 

CMS Proposes Changes in Inpatient Rates, Medicare DSH, and Wage Index

Last week the Centers for Medicare & Medicaid Services published a proposal detailing how it envisions paying for Medicare services in FY 2019 under its inpatient prospective payment system.

Yesterday this space features a summary of the proposed regulation, with an emphasis on aspects of the rule of greatest importance to private safety-net hospitals.

Today, we address Medicare inpatient rates, Medicare disproportionate share payments (Medicare DSH) and the Medicare cost report’s S-10 worksheet, and the Medicare area wage index.

Inpatient Rates

CMS proposes increasing Medicare inpatient rates 1.75 percent in FY 2019.  This reflects the projected hospital market basket update of 2.8 percent reduced by a 0.8 percentage point productivity adjustment, increased by a 0.5 percentage point adjustment required by legislation, and reduced 0.75 percentage points as required by the Affordable Care Act.

Medicare DSH Uncompensated Care Payments and the S-10

CMS proposes distributing $8.25 billion in Medicare DSH uncompensated care payments in FY 2019, a $1.5 billion increase from FY 2018, citing as its reason for this increase both an increase in the CMS Office of the Actuary’s estimate of payments that would otherwise be made for Medicare DSH and an updated estimate of the change in the percentage of uninsured individuals since 2014 based on the latest available data.

CMS also proposes continuing its phase-in of the use of S-10 data in the calculation of Medicare DSH uncompensated care payments.  FY 2019 would be year two of this phase-in, and CMS proposes using S-10 data from FY 2014 and FY 2015 cost reports, in combination with insured low-income days data from FY 2013 cost reports, to determine the distribution of Medicare DSH uncompensated care payments.

CMS is engaged in limited review of some of the uncompensated care data hospitals report on their S-10 form.  According to the proposed rule, these efforts have focused on three types of problems:  unreasonably high cost-to-charge ratios, significant increases in charity care from FY 2014 to FY 2015, and hospitals that report uncompensated care that exceeds 50 percent of their operating costs.

 Medicare Area Wage Index

Every three years CMS updates the wage index to reflect more recent data it collects from the occupational mix survey.  FY 2019 is the first year of a new three-year period for using updated data, and this will result in greater changes in wage indexes than might otherwise be expected from year to year.

CMS proposes changing the deadline for when a hospital that reclassifies from urban to rural will have that reclassification considered in the development of the wage index for a fiscal year.  This proposal would change the threshold from being based on the application’s date of submission to the application’s date of approval.

CMS also proposes changes that would address certain situations arising from lags between when wage index data is reported and when that data is evaluated for reclassification purposes.  These changes would address lag issues for new remote locations of hospitals located in counties participating in group reclassifications and for single-hospital MSAs where new hospitals have opened but that have no data in the wage index files for that MSA.

FY 2019 will mark the first year in which the imputed rural floor (which exists in states where there are no rural areas) will be eliminated.  CMS announced this in last year’s rule.  The only states to which the imputed rural floor applied were Delaware, New Jersey, and Rhode Island and this change will actually only affect hospitals in Rhode Island.

Wage Index Invitation to Comment

The proposed rule describes past efforts to revise the wage index, including past proposals from MedPAC and others.  It invites interested parties to submit comments on regulatory and policy improvements related to the wage index.

*          *          *

Tomorrow we will look at multi-campus hospitals, the Medicare and Medicaid electronic health record (EHR) incentive programs, and the Medicare hospital readmissions reduction program.  On Thursday we will examine the Medicare value-based purchasing program, the hospital inpatient quality reporting program, electronic clinical quality measures, and price transparency.

You also can learn more by reviewing the entire proposed 1883-page rule here or reading the CMS fact sheet here.

 

CMS Publishes Proposed FY 2019 Inpatient PPS Regulation

Last week the Centers for Medicare & Medicaid Services published a proposal detailing how it envisions paying for Medicare services in FY 2019 under its inpatient prospective payment system.

The following are the proposed rule’s highlights:

  • A 1.75 percent proposed increase of inpatient rates.
  • A $1.5 billion increase in the Medicare DSH uncompensated care payment pool during year two of the three-year phase-in of the use of S-10 uncompensated care data to calculate those payments.
  • The renaming of CMS’s “meaningful use” program to “promoting interoperability,” accompanied by major cuts in the number of measures hospitals must report as part of Medicare’s various quality programs.
  • A greater emphasis on the exchange of health care data among providers.
  • Several changes involving the Medicare area wage index system.
  •  Several requests for information:  one on promoting the exchange of data among hospitals, one on how to foster greater transparency of hospital prices, and one seeking recommendations for regulatory and policy changes to the Medicare wage index.

In the next three days this site will present more details about aspects of the proposed regulation that are of greatest interest to private safety-net hospitals.  The following is a list of what will be covered:

  • Tuesday – inpatient rates, Medicare disproportionate share (Medicare DSH) and the Medicare cost report’s S-10 worksheet, and the Medicare area wage index
  • Wednesday – multi-campus hospitals, the Medicare and Meidcaid electronic health record (EHR) incentive programs, and the Medicare hospital readmissions reduction program
  • Thursday – the Medicare value-based purchasing program, the hospital inpatient quality reporting program, electronic clinical quality measures, and price transparency

You also can learn more by reviewing the proposed 1883-page rule here or reading the CMS fact sheet here.

MedPAC Meets

The Medicare Payment Advisory Commission met last week in Washington, D.C. to address a number of Medicare reimbursement-related issues.

Among the subjects on MedPAC’s agenda were:

  • using payments to ensure appropriate access to and use of hospital emergency department services
  • uniform outcome measures for post-acute care
  • applying MedPAC’s principles for measuring quality: hospital quality incentives
  • Medicare coverage policy and use of low-value care
  • long-term issues confronting Medicare accountable care organizations
  • managed care plans for dual-eligible beneficiaries

While MedPAC’s policy and payment recommendations are not binding on Congress or the administration, its views are respected and influential and often become the basis for new public policy.

Go here to see the policy briefs and presentations offered to help guide MedPAC commissioners’ discussions about these and other issues.

Safety-Net Hospitals Improve More on Readmissions But Still More Likely to be Penalized

Hospitals that serve large numbers of minority patients are reducing their Medicare readmissions rates more than other hospitals but are still more likely to be penalized under Medicare readmissions reduction program.

This is one of the findings in a new study published in the journal Health Affairs.

According to the study, hospitals that serve larger numbers of minority patients – typically, safety-net hospitals – are more likely to be penalized for readmissions than other hospitals because even though they are reducing their readmissions rates faster than other hospitals, their performance is compared, unfavorably, to hospitals that had fewer Medicare readmissions prior to the launch of the readmissions reduction program.

This situation may change beginning in FY 2019 when a new system of evaluating hospital performance will be introduced.  Under this new system, hospitals will be compared only to hospitals that are similar in patient composition and not to all other hospitals.  NAUH was one of the most forceful and persistent advocates of this change in the program.

But until then, private safety-net hospitals remain more likely to be penalized by the readmissions reduction program than other others.

Learn more about how the composition of hospitals’ patients affects their likelihood of facing penalties under the readmissions reduction program by reading the report “Medicare Program Associated With Narrowing Hospital Readmissions Disparities Between Black and White Patients,” which can be found here, on the Health Affairs web site.

Readmissions Program Working; Expansion in Order?

The Medicare hospital readmissions reduction program is working, according to the Medicare Payment Advisory Commission.

And it may even be worth expanding to additional medical conditions, MedPAC members believe.

According to MedPAC, hospital readmissions among patients with medical conditions covered by the readmissions reduction program have declined faster than readmissions among patients with medical conditions not covered by the program, suggesting that expanding the program to additional medical conditions could lead to an even greater reduction in the number of avoidable Medicare-covered readmissions.

Learn more about changes in the readmission rate since the readmissions reduction program was introduced and whether those reductions can accurately be attributed to the program this MedPage Today article.

MedPAC Meets

The Medicare Payment Advisory Commission, which advises Congress on Medicare payment issues, met last week in Washington, D.C.

Among the issues on MedPAC’s agenda were:

  • paying for sequential stays in a unified Medicare payment system for post-acute care
  • encouraging Medicare beneficiaries to use higher-quality post-acute care providers
  • using payment policy to ensure appropriate access to and use of hospital emergency department services
  • the Centers for Medicare & Medicaid Services’ financial alignment demonstration for dual-eligible beneficiaries
  • the effectiveness of the Medicare hospital readmissions reduction program
  • population-based quality measures such as preventable admissions and home and community days

Go here, to MedPAC’s web site, to see the issue briefs and presentations that supported the discussion of these issues.

New Bill Proposes Greater 340B Accountability

A new bill proposed last week by Senator Chuck Grassley (R-IA) seeks to foster greater accountability among participants in the federal government’s section 340B prescription drug discount program.

The three-page bill is called the Ensuring the Value of the 340B Program Act of 2018, and according to a news release from the senator, its purpose is to require

…participating hospitals to report the total acquisition costs for drugs collected through the 340B program, as well as revenues received from all third party papers for those same drugs.

The 340B program provides discounts on prescription drugs dispensed on an outpatient basis to hospitals that qualify for participation based on how many low-income patients they serve.

Grassley’s proposal is the fourth 340B bill introduced in Congress in recent months as the program continues to draw attention from lawmakers.

Virtually all private safety-net hospitals participate in the 340B program and consider it an essential tool in serving the large numbers of low-income patients in the communities in which they are located.

Go here to see Grassley’s news release about his proposal and here to see the bill itself.