Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives

1. Readmissions for Medicaid Patients: State-Level Benchmarks and Initiatives AHRQ Annual Conference September 10, 2012 David Kelley, M.D., M.P.A. Office of Medical Assistance Programs Pennsylvania Department of Public Welfare The 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.

2. Overview Readmission Data Project • Specifications for reporting and analysis • Results • Overall readmissions • Payment • MDC • State-specific report (sample) • Conclusions State Readmissions Policies 2

3. Readmission Data Project Acknowledgements • 18 states that contributed state-level summary data • Tara Trudnak, Ph.D. and Gerry Fairbrother, Ph.D., AcademyHealthfor analysis. • Halley Brunsteter, Kevin Koenig, Jessica Teel and Veronica Thomas at AcademyHealth for analysis assistance. • David Kelley, M.D. and Judy Zerzan, M.D. for leadership on the MMDLN readmissions workgroup and input to this analysis. • Katherine Griffith, M.H.S. at AcademyHealth for handling data submissions by individual states. 3

4. Readmission Data ProjectPurpose • 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 4

5. MethodsReadmission Specifications 5

6. MethodsReadmission 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. 6

7. MethodsReadmission 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) 7

8. MethodsReporting 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 8

9. MethodsReporting 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) 9

10. 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) 10

11. ResultsOverall Readmissions 11

12. Average 30-day Readmission Rates *CMS (MSIS) for the Medicaid 2009 data. **AHRQ HCUP Nationwide Readmission Database 2010. 12

13. Results30-Day Readmission Rates by Clinical Categories and Population Range (11.7%-21.5%) Range (3.1%-14.0%) Range (0.9%-6.2%) Range (1.2%-6.4%) OB Pediatric OB Adult Non-OB Pediatric Non-OB Adult (0-20 yrs) (21-64 yrs) (0-20 yrs) (21-64 yrs) 13

14. ResultsAverage 30-day readmission rates by population (physical health only) 14

15. ResultsAverage 30-day readmission rates by Gender (physical health only) 15

16. ResultsAverage 30-day readmission rates for by Age (physical health only) 16

17. ResultsAverage 30-day Readmissions by Health Plan Type (physical health only) 17

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

19. ResultsReadmission Payment 19

20. Readmissions Payment for 18 States Payment for Readmissions Payment for Total Admissions • % Readmission Payment = • % Readmission Payment: 12.5% • Average Total Readmission Payment: 75.4 million • Total Readmission Payment: 1.4 billion 20

21. ResultsAverage percent of 30-day readmission payment by health plan(physical health only) 21

22. ResultsAverage percent of 30-day readmission payment by population(physical health only) 22

23. Results30-Day Readmissions by Major Diagnostic Categories 23

24. ResultsTop 5 Diagnoses by Share of All 30-day Readmissions All Ages (0-64yrs) 17 Participating States 24

25. ResultsTop 5 Diagnoses by Share of All 30-day Readmissions for 0-12 yrs 9 Participating States 25

26. ResultsTop 5 Diagnoses by Share of All 30-day Readmissions for 13-20 yrs 9 Participating States 26

27. ResultsTop 5 Diagnoses by Share of All 30-day Readmissions for 21-64 yrs 9 Participating States 27

28. State-specific Report 28

29. 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 29

30. 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 30

31. Conclusions • The diagnoses that contributed to the highest share of readmissions payment for all ages: • Mental Disorders • Diseases of the Respiratory System 31

32. State Readmissions Policies 32

33. 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.” 33

34. 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. 34

35. Other Policies or Programs • Case management • Within health plans • Embedded into practice • Transitions of care programs • STateAction on Avoidable Rehospitalizations(STAAR) • ProjectRED • Discharge planning 35