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.

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

Readmission Data Project Acknowledgements  18 states that contributed state-level summary data  Tara Trudnak, Ph.D. and Gerry Fairbrother, Ph.D., AcademyHealth for 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

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 4

Methods Readmission Specifications  5

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

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) 7

Methods Reporting Variables/Stratification 8 Patient Demographics  Age –Newborn and Pediatric (0-20 yrs): <1, 1-12, –Adult (21-64 yrs): 21-44,  Gender –Female –Male  Race/ethnicity –White, Black, Hispanic, Asian/Pacific Island, Native American, Other, Unknown

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) 9

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

Results Overall Readmissions 11

Average 30-day Readmission Rates MMDLN Medicaid patients, 18 states (2010) CMS Medicaid patients, 45 states (2009)* AHRQ Private patients (2010)** Total (age 0 to 64) 8.8% Total (age 1 to 64) 14.0%8.6% OB, regardless of age 3.3% OB, regardless of age 5.5%3.4% Non-OB pediatrics, age % Non-OB pediatrics, age %8.2% Non-OB adults, age % Non-OB adults, age %10.4% 12 *CMS (MSIS) for the Medicaid 2009 data. **AHRQ HCUP Nationwide Readmission Database 2010.

Results 30-Day Readmission Rates by Clinical Categories and Population 13 OB Pediatric OB Adult Non-OB Pediatric Non-OB Adult (0-20 yrs) (21-64 yrs) (0-20 yrs) (21-64 yrs) Range (0.9%-6.2%) Range (1.2%-6.4%) Range (3.1%-14.0%) Range (11.7%-21.5%)

Results Average 30-day readmission rates by population (physical health only) 14

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

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

Results Average 30-day Readmissions by Health Plan Type (physical health only) 17

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

Results Readmission Payment 19

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

Results Average percent of 30-day readmission payment by health plan (physical health only) 21

Results Average percent of 30-day readmission payment by population (physical health only) 22

Results 30-Day Readmissions by Major Diagnostic Categories 23

Results Top 5 Diagnoses by Share of All 30-day Readmissions All Ages (0-64yrs) Category Share of all Readmissions (Category readmissions/Total readmissions) Share of Payment for Readmissions (Category payment for readmissions/Total payment for readmissions) Readmission Rate (Category readmissions/ Category Admissions) % Total Hospital Payment for Readmissions (Category payment for readmissions/Category payment for admissions) 1. Mental Disorders 19.7%12.6%17.9%15.9% 2. Complications of Pregnancy, Childbirth, & the Puerperium 11.7%6.2%4.2%4.9% 3. Diseases of the Respiratory System 9.4%11.6%12.0%15.4% 4. Diseases of the Digestive System 8.5%9.0%15.4%16.8% 5. Diseases of the Circulatory System 8.0%10.2%17.2%15.1% 17 Participating States 24

Results Top 5 Diagnoses by Share of All 30-day Readmissions for 0-12 yrs Category Share of All Readmissions Share of Payment for Readmissions Readmission Rate % Total Hospital Payment for Readmissions 1. Diseases of the Respiratory System 21.3%19.4%6.9%12.1% 2. Certain Conditions Originating in the Perinatal Period 17.1%12.2%30.7%11.6% 3. Mental Disorders9.1%6.3%11.2%12.6% 4. Symptoms, Signs, & Ill- Defined Conditions 7.2%5.9%12.9%22.6% 5. Injury & Poisoning7.0%8.2%11.2%13.7% 25 9 Participating States

Results Top 5 Diagnoses by Share of All 30-day Readmissions for yrs Category Share of All Readmissions Share of Payment for Readmissions Readmission Rate % Total Hospital Payment for Readmissions 1. Mental Disorders32.6%29.4%12.0%12.9% 2. Complications of Pregnancy, Childbirth & the Puerperium 30.9%16.2%4.2%4.8% 3. Injury & Poisoning6.4%9.4%11.5%9.9% 4. Diseases of the Blood & Blood-Forming Organs 5.0%6.5%25.8%27.9% 5. Diseases of the Digestive System 4.5%5.8%9.6%11.3% 9 Participating States 26

Results Top 5 Diagnoses by Share of All 30-day Readmissions for yrs Category Share of All Readmissions Share of Payment for Readmissions Readmission Rate % Total Hospital Payment for Readmissions 1. Mental Disorders20.0%11.3%23.9%19.7% 2. Complications of Pregnancy, Childbirth & the Puerperium 12.7%7.6%4.2%4.6% 3. Diseases of the Circulatory System 10.4%14.4%17.7%14.9% 4. Diseases of the Digestive System 9.3%10.5%17.2%17.5% 5. Diseases of the Respiratory System 8.4%10.6%17.4%18.2% 27 9 Participating States

State-specific Report 28

Conclusions  Overall, MCOs had the lowest readmission rates  Non-Obstetric adults had the highest readmission rate  Readmission rates were highest among the year old age groups  Readmission rates were higher for males than females 29

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

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

State Readmissions Policies 32

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

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

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 35