apr-drgs : readmission module

1. APR-DRGs : Readmission Module 3M HIS Clinical Research Department

2. 9/27/2011

3. 9/27/2011 3M HIS Clinical Research Experience 3M HIS Experience in developing classification and payment/quality systems: Development of the first DRG Prospective Payment System (PPS) in NJ in 1980 Under contract with CMS, maintenance of the CMS DRGs since the inception of Medicare PPS in 1983 including recently released MS-DRGs Design and development of the first outpatient PPS for Iowa Medicaid Under contract with CMS, maintenance of the APCs since the inception of the Medicare outpatient PPS in 2000 Under contract with CMS, design, development and maintenance of acute long term care hospital PPS Extensive experience in implementing PPS systems internationally including a prospective budgeting system based on APR-DRGs for Belgium Design and development of ICD-10 PCS Design and development of Potentially Preventable Readmission (PPRs) and Potentially Preventable Complication (PPCs) using APR-DRGs Mapping of ICD-9-CM Diagnoses to ICD-10-CM Diagnoses Under contract to the Federal Government, development of Clinical Risk Groups (CRGs) and CRxGs (privately funded - using pharmaceutical data) for population profiling/ risk adjustment/ physician profiling Under contract with NIMH, working together with Johns Hopkins/ U of Maryland to develop new payment system for inpatient mental health services.

4. 9/27/2011 In Every Country There Are Four Sources for Variation in Health Services Patient/family variation Caregiver/clinician variation Hospital/system variation Community variation Payers rarely tie financial or quality incentives to any of these sources of variation. Today we have the tools such as readmissions to measure each of these sources of variation for each type of health care encounter. Payers need to offer quality and financial incentives to aggressively control the costs and improve the quality of this variation.

5. 9/27/2011 Value can be measured for each of the 4 kinds of health care encounters Value can be measured for each type of health care encounter Ambulatory Patient Groups (APGs) � Visits All-Patient Refined DRGs (APR-DRGs) � Hospital Stays Clinical Risk Groups (CRGs) � EpisodesAPR-DRGs/CRGs plus Health Status-Long Term Care

6. 9/27/2011 Why Develop a Method to Identify Potentially Preventable Readmissions? Interest in comparing healthcare provider performance to enhance quality of care Interest in developing pay for performance systems Previous emphasis on length of stay, cost and mortality Address only limited aspects of quality of care Death in hospital is a relatively rare event Hospital readmission rates will provide additional information on quality of care and need for better coordination of services Note this presentation focuses on hospital not human centric readmission rates. Costs associated with readmissions are substantial � approximately 30 billion in play for Medicare

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8. 9/27/2011 Assumptions Underlying the Development of PPRs Not all readmissions are preventable Patients who have had a problem with the quality of inpatient care or outpatient care following discharge will be more likely to be readmitted Discharged too sick, too quick Poor discharge planning Poor follow-up care A hospital with these types of quality problems will be more likely to have higher rates of readmissions For certain types of patients Across the board

9. 9/27/2011 Readmissions Can Be Prevented By: Providing excellent care during the first hospitalization; and� Putting into place the best possible coordination plans with the outpatient setting � including both the outpatient health professional team and the patient/family/caregiver.

10. 9/27/2011 Readmission Overview

11. 9/27/2011 Research Approach for Development of PPRs Define exclusion criteria for identifying initial discharges for which a subsequent readmission is excluded from consideration as a PPR (e.g. discharged against medical advice) Develop criteria for determining if a readmission is potentially preventable (i.e. a PPR) Develop a method of determining the risk of a PPR occurring and develop a method for computing actual and expected hospital PPR rates Test methodology in large databases

12. 9/27/2011 PPR Initial Discharge Exclusions If any of the following conditions apply to the initial discharge, a subsequent readmission is excluded from consideration as a PPR Major or metastatic malignancies Neonates Multiple trauma, burns Left against medical advice Transferred to another acute care hospital Obstetrical Other exclusions Specific eye procedures and infections Cystic fibrosis-pulm dx Died

13. 9/27/2011 Research Approach for Development of PPRs Define exclusion criteria for identifying initial discharges for which a subsequent readmission is excluded from consideration as a PPR (e.g. discharged against medical advice) Develop criteria for determining if a readmission is potentially preventable (i.e. a PPR) Identify �chains� of related readmissions Develop a method of determining the risk of a PPR occurring and develop a method for computing actual and expected hospital PPR rates Test methodology in large databases

14. 9/27/2011 Determining the Potentially Preventability of a Readmission � a General Rule If for a specific type of discharge (e.g., coronary bypass surgery) a hospital that has a statistically significant higher rate of specific types of readmissions than comparable hospitals, the health care team will believe that opportunities to improve exist for either quality of care and/or both coordination process/discharge planning with the outpatient sector.

15. 9/27/2011 Clinical Criteria for Determining Potentially Preventable Readmissions The reason for the readmission can be a consequence of the prior discharge. Poor quality during the prior hospitalization Poor coordination between the inpatient and outpatient health care team The reason for readmission can be a consequence of inadequate outpatient follow-up If the reason for readmission is unrelated to the prior hospitalization, it is not considered a potentially preventable readmission (e.g., admission for trauma) and is not designated as a PPR

16. 9/27/2011 General Guidelines for PPRs

17. 9/27/2011 PPRs Must Be Clinically Related To Prior Discharge � either the pdx and/or sdx Case 1: PPR Initial discharge: Asthma Readmission 8 days post discharge: Asthma Case 2: PPR Initial discharge: Acute MI Readmission 6 days post discharge with Diabetes Mellitus Case 3: Not a PPR Initial discharge: Pneumonia Readmission 4 days post discharge: Fractured femur & skull sustained in motor vehicle accident Case 4: Not a PPR Initial discharge: CHF Readmission 6 days post discharge: Appendectomy Case 5: PPR Initial discharge: Abdominal Pain Readmission 2 days post discharge: Appendectomy

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19. 9/27/2011 Readmission Chain A �PPR chain� is an initial discharge followed by a number of clinically related readmissions A PPR chain terminates if a readmission meets any of the following criteria: Is outside the x day window of time Is clinically unrelated to initial discharge Left against medical advice Is a transfer to another acute care hospital Meets discharge exclusion criteria Other trauma admission Died

20. 9/27/2011 No hospital discharges in prior x day window Not an excluded reason for admission Not LAMA Not transferred to other hospital

21. 9/27/2011 Example of PPR Chains

22. 9/27/2011 Research Approach for Development of PPRs Define exclusion criteria for identifying initial discharges for which a subsequent readmission is excluded from consideration as a PPR (e.g. discharged against medical advice) Develop criteria for determining if a readmission is potentially preventable (i.e. a PPR) Identify �chains� of related readmissions Develop a method of determining the risk of a PPR occurring and develop a method for computing actual and expected hospital PPR rates Test methodology in large databases

23. 9/27/2011 Discussion Issues Readmission window of time Readmission to same hospital or any hospital Outlier chains Computation of expected value for beneficiaries with mental illness Age groups (include Pediatrics?)

24. 9/27/2011 Outliers Chains Some patients can have long chains of PPRs in one initial discharge Some patients can have many initial discharges with one or more PPRs E.g. sickle cell.

25. 9/27/2011 Beneficiaries with Mental Health Illness These patients with other co-existing mental health illnesses (e.g. patient with diabetes and psychosis who is admitted for complications of diabetes) will be readmitted at a higher rate than patients without a mental health issue. Any initial discharge with mental health diagnosis could be excluded However, this would represent a disservice to these patients and not encourage hospitals to implement effective coordinated care programs Adjust expected PPR rate calculation for patients with and without significant chronic mental illness.

26. 9/27/2011 Issues for Discussion in Public Reporting Start with one number and then allow the user to dig deeper � how deep? Types of hospitals � like with like or across the board? Minimum numbers needed for comparison Age range breakout reports Visual display

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34. 9/27/2011 Types of Reports Overall readmission Medical vs surgical vs mental health/substance abuse Major Surgery � one report No Major Medical Service line reports split by medical/surgical DRG specific analyses (when volume permits) CABG, MI, Asthma

35. 9/27/2011 Communication Issues Disease specific � which diseases are of greatest interest to Medicaid consumers? Low income issues � barriers to access for information and thus need to tailor reports that will be accessible to either low income populations and/or their representatives.

36. 9/27/2011 Final Thoughts Data becomes increasingly clinically valid as all parties at the health care table � from consumers to providers to health care professionals use the data. The public is very obviously interested in mortality; but it is a rare (relatively) event and thus should be complemented with post admission patient complications, readmissions and other outcome variables that are certainly of interest to the public and have a bottom line impact on reducing overall health care costs.

37. 9/27/2011 Summary The 3M HIS Clinical Research group is committed to developing case mix tools that measure value: outcome quality/ payment. Readmissions and PPCs are the two of most critical (from a cost and quality point of view) outcomes variables one can measure.