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The penalties are going up in Medicare’s hospital readmission reduction program. Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule released April 26.
The proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures. Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget. At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement. "This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program. The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first domain are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate. CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well. Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," Mr. Johnson said. "Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff."
The agency is scheduled to release its final rule by Aug. 1.
| Dr. Frank Pomposelli |
It’s a slippery slope at best. Take for example the mandated push towards electronic medical records (EMR). Will they improve safety and outcomes? Perhaps. Will they reduce costs? I doubt it. EMRs are costly to implement (up to a billion dollars for one very large system that I am familiar with) and reduce efficiency for physicians. The vast array of commercially available and home grown products cannot communicate with one another and HIPPA regulations make it impossible for information to be easily shared between two different health care systems caring for the same patient. The current initiatives by CMS outlined above are another example of using payment reduction mandates (AKA cost containment) in an attempt to improve outcomes.
I doubt any physician or surgeon would dispute the desire or need to reduce readmissions and the rate of hospital acquired conditions like pressure decubiti, venous thrombo-embolism, line infections etc. However, I wonder whether reducing reimbursement, even though it’s the only method available, is either fair or effective. We already spend an enormous amount of time and resources on disposition planning from the moment a patient enters the hospital until the day they leave and work feverishly to get patients out of the hospital as quickly as possible once their treatment is complete. Occasionally, the care team even finds themselves in the uncomfortable situation of nearly pushing someone they have treated out the door. It stands to reason that the pressure to reduce length of stay will result in a somewhat higher rate of readmission-a trade off that recognizes that we are not perfect and neither are our patients. In my experience, the poor and disenfranchised are especially at risk for readmission. Undoubtedly those hospitals that care for a disproportionate number of poor will be unfairly penalized. Is it reasonable to pressure hospitals simultaneously on length of stay and readmissions? I think not. Moreover, is it reasonable to pick a high volume, high reimbursement program like joint replacement just because it’s a big ticket item? Smaller programs may actually represent areas where there is more room for improvement.
My ire is less aroused with regard to hospital acquired conditions. We can and must do a better job in preventing avoidable complications to our patients. Many but not all hospital acquired morbidities result from deficiencies in the system of care that all hospitals, regardless of the demographic they serve can and must correct. Again, hospitals serving the poor may be unfairly targeted since many have less in house resources than larger wealthier systems serving a more affluent patient population. Moreover, fairness and accuracy requires risk adjusted metrics- something that policy makers don’t always recognize without input from us.
After 26 years in clinical practice, many of which have been spent working with my hospital to correct or improve these problems, I’ve come to realize that in a system as complex as a hospital, achieving success in these areas is difficult and requires not only commitment and hard work but also resources. If resources are going to be continuously cut while expecting us to reduce in hospital complications, keep down length stay and reduce the rate of admissions, I suspect all we’ll wind up with is further reductions in compensation with little or no benefit to patients. The skeptics among us undoubtedly feel that is the true motivation behind these initiatives. I hope they are wrong.
Dr. Frank Pomposelli is chair of surgery, St. Elizabeth’s Medical Center, Boston, and associate medical editor of VASCULAR SPECIALIST.
| Dr. Frank Pomposelli |
It’s a slippery slope at best. Take for example the mandated push towards electronic medical records (EMR). Will they improve safety and outcomes? Perhaps. Will they reduce costs? I doubt it. EMRs are costly to implement (up to a billion dollars for one very large system that I am familiar with) and reduce efficiency for physicians. The vast array of commercially available and home grown products cannot communicate with one another and HIPPA regulations make it impossible for information to be easily shared between two different health care systems caring for the same patient. The current initiatives by CMS outlined above are another example of using payment reduction mandates (AKA cost containment) in an attempt to improve outcomes.
I doubt any physician or surgeon would dispute the desire or need to reduce readmissions and the rate of hospital acquired conditions like pressure decubiti, venous thrombo-embolism, line infections etc. However, I wonder whether reducing reimbursement, even though it’s the only method available, is either fair or effective. We already spend an enormous amount of time and resources on disposition planning from the moment a patient enters the hospital until the day they leave and work feverishly to get patients out of the hospital as quickly as possible once their treatment is complete. Occasionally, the care team even finds themselves in the uncomfortable situation of nearly pushing someone they have treated out the door. It stands to reason that the pressure to reduce length of stay will result in a somewhat higher rate of readmission-a trade off that recognizes that we are not perfect and neither are our patients. In my experience, the poor and disenfranchised are especially at risk for readmission. Undoubtedly those hospitals that care for a disproportionate number of poor will be unfairly penalized. Is it reasonable to pressure hospitals simultaneously on length of stay and readmissions? I think not. Moreover, is it reasonable to pick a high volume, high reimbursement program like joint replacement just because it’s a big ticket item? Smaller programs may actually represent areas where there is more room for improvement.
My ire is less aroused with regard to hospital acquired conditions. We can and must do a better job in preventing avoidable complications to our patients. Many but not all hospital acquired morbidities result from deficiencies in the system of care that all hospitals, regardless of the demographic they serve can and must correct. Again, hospitals serving the poor may be unfairly targeted since many have less in house resources than larger wealthier systems serving a more affluent patient population. Moreover, fairness and accuracy requires risk adjusted metrics- something that policy makers don’t always recognize without input from us.
After 26 years in clinical practice, many of which have been spent working with my hospital to correct or improve these problems, I’ve come to realize that in a system as complex as a hospital, achieving success in these areas is difficult and requires not only commitment and hard work but also resources. If resources are going to be continuously cut while expecting us to reduce in hospital complications, keep down length stay and reduce the rate of admissions, I suspect all we’ll wind up with is further reductions in compensation with little or no benefit to patients. The skeptics among us undoubtedly feel that is the true motivation behind these initiatives. I hope they are wrong.
Dr. Frank Pomposelli is chair of surgery, St. Elizabeth’s Medical Center, Boston, and associate medical editor of VASCULAR SPECIALIST.
| Dr. Frank Pomposelli |
It’s a slippery slope at best. Take for example the mandated push towards electronic medical records (EMR). Will they improve safety and outcomes? Perhaps. Will they reduce costs? I doubt it. EMRs are costly to implement (up to a billion dollars for one very large system that I am familiar with) and reduce efficiency for physicians. The vast array of commercially available and home grown products cannot communicate with one another and HIPPA regulations make it impossible for information to be easily shared between two different health care systems caring for the same patient. The current initiatives by CMS outlined above are another example of using payment reduction mandates (AKA cost containment) in an attempt to improve outcomes.
I doubt any physician or surgeon would dispute the desire or need to reduce readmissions and the rate of hospital acquired conditions like pressure decubiti, venous thrombo-embolism, line infections etc. However, I wonder whether reducing reimbursement, even though it’s the only method available, is either fair or effective. We already spend an enormous amount of time and resources on disposition planning from the moment a patient enters the hospital until the day they leave and work feverishly to get patients out of the hospital as quickly as possible once their treatment is complete. Occasionally, the care team even finds themselves in the uncomfortable situation of nearly pushing someone they have treated out the door. It stands to reason that the pressure to reduce length of stay will result in a somewhat higher rate of readmission-a trade off that recognizes that we are not perfect and neither are our patients. In my experience, the poor and disenfranchised are especially at risk for readmission. Undoubtedly those hospitals that care for a disproportionate number of poor will be unfairly penalized. Is it reasonable to pressure hospitals simultaneously on length of stay and readmissions? I think not. Moreover, is it reasonable to pick a high volume, high reimbursement program like joint replacement just because it’s a big ticket item? Smaller programs may actually represent areas where there is more room for improvement.
My ire is less aroused with regard to hospital acquired conditions. We can and must do a better job in preventing avoidable complications to our patients. Many but not all hospital acquired morbidities result from deficiencies in the system of care that all hospitals, regardless of the demographic they serve can and must correct. Again, hospitals serving the poor may be unfairly targeted since many have less in house resources than larger wealthier systems serving a more affluent patient population. Moreover, fairness and accuracy requires risk adjusted metrics- something that policy makers don’t always recognize without input from us.
After 26 years in clinical practice, many of which have been spent working with my hospital to correct or improve these problems, I’ve come to realize that in a system as complex as a hospital, achieving success in these areas is difficult and requires not only commitment and hard work but also resources. If resources are going to be continuously cut while expecting us to reduce in hospital complications, keep down length stay and reduce the rate of admissions, I suspect all we’ll wind up with is further reductions in compensation with little or no benefit to patients. The skeptics among us undoubtedly feel that is the true motivation behind these initiatives. I hope they are wrong.
Dr. Frank Pomposelli is chair of surgery, St. Elizabeth’s Medical Center, Boston, and associate medical editor of VASCULAR SPECIALIST.
The penalties are going up in Medicare’s hospital readmission reduction program. Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule released April 26.
The proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures. Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget. At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement. "This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program. The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first domain are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate. CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well. Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," Mr. Johnson said. "Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff."
The agency is scheduled to release its final rule by Aug. 1.
The penalties are going up in Medicare’s hospital readmission reduction program. Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule released April 26.
The proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures. Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget. At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement. "This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program. The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first domain are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate. CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well. Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," Mr. Johnson said. "Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff."
The agency is scheduled to release its final rule by Aug. 1.