Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015

on Tuesday, 31 March 2015. All News Items | Quality | Documentation

Healthcare Industry Calls for Program Risk Adjustment Changes

“Never doubt that a small group of thoughtful, committed, citizens can change the world; indeed, it is the only thing that ever has.”

-Margaret Mead

Quality initiatives were a key focus in the Inpatient Prospective Payment System (IPPS) 2015 Final Rule. As a matter of fact, the Hospital Acquired Condition (HAC) Program, the last of the three Affordable Care Act (ACA) mandated quality programs was implemented on October 1, 2014. At the same time, the first two quality programs, the Hospital Value Based Purchasing (VBP) Program and the Hospital Readmission Reduction Program (HRRP) were respectively entering into their third year of program incentives and penalties.

This January, Health and Human Services Secretary Sylvia M. Burwell announced aggressive goals of moving our healthcare system towards paying providers based on quality rather than quantity. It is with an eye towards quality that health industry leaders and members of Congress have found fault in the risk adjustment methodology in the HRRP and are calling for change. On March 10th, U.S. Senators Rob Portman (R-OH) and Joe Manchin (D-WV) and Representatives James Renacci (R-OH) and Eliot Engel (D-NY) introduced the Establishing Beneficiary Equity in the Hospital Readmission Reduction Program Act of 2015 (S.6888) (H.R. 1343). This bill would require the CMS to account for socio-economic status when calculating the risk-adjusted readmission penalties.

HRRP Risk Adjustment Background

Currently HRRP measures are adjusted “for variables (i.e., age, comorbid diseases, and indicators of patient frailty) that are clinically relevant and have strong relationships with the outcome. For each patient, risk-adjustment variables are obtained from inpatient, outpatient, and provider Medicare administrative claims data extending 12 months prior to, and including, the index admission.”

“The measures also do not adjust for socioeconomic status (SES) because the association between SES and health outcomes can be due, in part, to differences in the quality of healthcare groups of patients with varying SES receive. Risk adjusting for SES could also mask important disparities and minimize incentives to improve outcomes for vulnerable populations. The intent is for the measures to adjust for patient demographic and clinical characteristics while illuminating important quality differences. Additionally, recent analyses have shown that hospitals caring for high proportions of low SES patients perform similarly on the measures to hospitals caring for low proportions of low SES patients.”

Industry Response to Lack of Socio-economic Risk Adjustment

“As a former businessman with a long record of experience in the health care industry, it’s clear that the HRRP unfairly penalizes safety-net and teaching hospitals – taking valuable resources from those who are in need of them most,” said Congressman Renacci. “There is no question that this money could be better spent helping patients avoid rehospitalization. Our bill reflects that.”

“The Establishing Beneficiary Equity in the Hospital Readmission Program Act that Rep. Renacci and I have introduced in the House, and Senators Portman and Manchin have introduced in the Senate, would make a vital correction to the HRRP hospital readmission formula, which currently treats certain hospitals in lower socioeconomic communities unfairly,” Congressman Engel said. “Hospitals must be held accountable for providing high quality care to all patients, but as numerous studies have shown, socioeconomic factors can influence patient outcomes. Therefore, hospitals serving our neediest populations shouldn’t be penalized for doing so. This is a piece of common sense legislation and I hope it passed in the House and Senate quickly.”

The American Hospital Association (AHA) released a statement indicating that “the legislation will greatly improve the fairness of readmission penalties by taking into account both the proportion of the hospital’s patients eligible for both Medicare and Medicaid and the patient’s sociodemographic status. This recalibration ensures hospital performance is compared equally while maintaining an incentive for all hospitals to reduce unnecessary readmissions.”

What You Can Do Now

The 2014 Measures Updates and Specifications Reports found on the QualityNet (Q-Net) web site indicate that, “the measures adjust for case mix differences among hospitals based on the clinical status of the patient at the time of the index admission. Accordingly, only comorbidities that convey information about the patient at that time or in the 12 months prior, and not complications that arise during the course of the hospitalization, are included in the risk adjustment.”

Both pieces of legislation have been assigned to a committee so we wait. While you wait take the time to identify comorbid diseases that can impact your hospitals Risk Standardized Readmission Rates (RSRR). Each HRRP measure has its own table of risk-adjustment variables. Have your Quality and Clinical Documentation professionals work together to first identify the variables and then ensure the completeness of Physicians documentation of a patient’s past medical and surgical history in the medical record. The Risk Adjustment- Risk Variable Tables for each measure are listed below.

 

Table D.1.2 – Risk Variables for AMI Measure

VariableDescription
n/a

Age-65 (years above 65, continuous)

n/a

Male

ICD-9-CM V45.82, 00.66, 36.01, 36.02, 36.05, 36.06, 36.07

History of PTCA

ICD-9-CM V45.81, 36.10–36.16

History of CABG

ICD-9-CM 410.00-410.19

Anterior myocardial infarction

ICD-9-CM 410.20-410.69

Other location of myocardial infarction

CC 1, 3-6

History of infection

CC 7

Metastatic cancer and acute leukemia

CC 8-12

Cancer

CC 15-20, 119, 120

Diabetes mellitus (DM) and DM complications

CC 21

Protein-calorie malnutrition

CC 22, 23

Disorders of fluid/electrolyte/acid-base

CC 47

Iron deficiency and other anemias and blood disease

CC 49, 50

Dementia and other specified brain disorders (senility)

CC 67-69, 100-102, 177, 178

Hemiplegia, paraplegia, paralysis, functional disability

CC 80

Congestive heart failure

CC 81, 82

Acute coronary syndrome

CC 83

Angina pectoris, old myocardial infarction

CC 84

Coronary atherosclerosis/other chronic ischemic heart disease

CC 86

Valvular and rheumatic heart disease

CC 92, 93

Arrhythmias

CC 95, 96

Stroke

CC 97-99, 103

Cerebrovascular disease

CC 104-106

Vascular or circulatory disease

CC 108

Chronic obstructive pulmonary disease

CC 110

Asthma

CC 111-113

Pneumonia

CC 129, 130

End-stage renal disease or dialysis

CC 131

Renal failure

CC 136

Other urinary tract disorders

CC 148, 149

Decubitus ulcer or chronic skin ulcer

 

Table D.2.2 – Risk Variables for HF Measure

VariableDescription
n/a

Age-65 (years above 65, continuous)

n/a

Male

ICD-9-CM V45.81, 36.10–36.16

History of CABG

CC 7

Metastatic cancer and acute leukemia

CC 8-12

Cancer

CC 15-20, 119, 120

Diabetes mellitus or DM complications

CC 21

Protein-calorie malnutrition

CC 22, 23

Disorders of fluid, electrolyte, acid-base

CC 25-30

Liver or biliary disease

CC 34

Peptic ulcer, hemorrhage, other specified gastrointestinal disorders

CC 36

Other gastrointestinal disorders

CC 44

Severe hematological disorders

CC 47

Iron deficiency and other anemias and blood disease

CC 49, 50

Dementia and other specified brain disorders

CC 51-53

Drug/alcohol abuse/dependence/psychosis

CC 54-56

Major psychiatric disorders

CC 58

Depression

CC 60

Other psychiatric disorders

CC 67-69, 100-102, 177, 178

Hemiplegia, paraplegia, paralysis, functional disability

CC 79

Cardio-respiratory failure and shock

CC 80

Congestive heart failure

CC 81, 82

Acute coronary syndrome

CC 83, 84

Coronary atherosclerosis or angina

CC 86

Valvular and rheumatic heart disease

CC 92, 93

Specified arrhythmias

CC 94

Other and unspecified heart disease

CC 95, 96

Stroke

CC 104-106

Vascular or circulatory disease

CC 108

Chronic obstructive pulmonary disease

CC 109

Fibrosis of lung and other chronic lung disorders

CC 110

Asthma

CC 111-113

Pneumonia

CC 129, 130

End-stage renal disease or dialysis

CC 131

Renal failure

CC 132

Nephritis

CC 136

Other urinary tract disorders

CC 148, 149

Decubitus ulcer or chronic skin ulcer

 

Table D.3.2 – Risk Variables for Pneumonia Measure

VariableDescription
n/a

Age-65 (years above 65, continuous)

n/a

Male

ICD-9-CM V45.81, 36.10–36.16

History of CABG

CC 1, 3-6

History of infection

CC 2

Septicemia/shock

CC 7

Metastatic cancer and acute leukemia

CC 8

Lung, Upper Digestive Tract, and Other Severe Cancers

CC 9-10

Other major cancers

CC 15-20, 119, 120

Diabetes and DM complications

CC 21

Protein-calorie malnutrition

CC 22, 23

Disorders of fluid, electrolyte, acid-base

CC 36

Other gastrointestinal disorders

CC 44

Severe hematological disorders

CC 47

Iron deficiency or other anemias and blood disease

CC 49, 50

Dementia or other specified brain disorders

CC 51-53

Drug/alcohol abuse/dependence/psychosis

CC 54-56

Major psychiatric disorders

CC 60

Other psychiatric disorders

CC 67-69, 100-102, 177, 178

Hemiplegia, paraplegia, paralysis, functional disability

CC 79

Cardio-respiratory failure and shock

CC 80

Congestive heart failure

CC 81, 82

Acute coronary syndrome

CC 83, 84

Coronary atherosclerosis or angina

CC 86

Valvular and rheumatic heart disease

CC 92, 93

Specified arrhythmias

CC 95, 96

Stroke

CC 104-106

Vascular or circulatory disease

CC 108

Chronic obstructive pulmonary disease

CC 109

Fibrosis of lung and other chronic lung disorders

CC 110

Asthma

CC 111-113

Pneumonia

CC 114

Pleural effusion/pneumothorax

CC 115

Other lung disorders

CC 129, 130

End-stage renal disease or dialysis

CC 131

Renal failure

CC 135

Urinary tract infection

CC 136

Other urinary tract disorders

CC 148, 149

Decubitus ulcer or chronic skin ulcer

CC 157

Vertebral fractures

CC 162

Other injuries

 

Table D.4.2 – Risk Variables for COPD Measure

VariableDescription
n/a

Age (years above 65, continuous)

ICD-9 procedure codes: 93.90, 96.70, 96.71, 96.72

History of Mechanical Ventilation

ICD-9 diagnosis codes: 327.20, 327.21, 327.23, 327.27, 327.29, 780.51, 780.53, 780.57

Sleep Apnea

CC 1, 3-6

History of Infection

CC 7

Metastatic Cancer and Acute Leukemia

CC 8

Lung, Upper Digestive Tract, and Other Severe Cancers

CC 9-11

Lymphatic, Head and Neck, Brain, and Other Major Cancers; Breast, Colorectal and other Cancers and Tumors; Other Respiratory and Heart Neoplasms

CC 12

Other Digestive and Urinary Neoplasms

CC 15-20, 119-120

Diabetes Mellitus (DM) or DM Complications

CC 21

Protein-Calorie Malnutrition

CC 22-23

Disorders of Fluid/Electrolyte/Acid-Base

CC 24

Other Endocrine/Metabolic/Nutritional Disorders

CC 32

Pancreatic Disease

CC 34

Peptic Ulcer, Hemorrhage, Other Specified Gastrointestinal Disorders

CC 36

Other Gastrointestinal Disorders

CC 44

Severe Hematological Disorders

CC 47

Iron Deficiency or Other/Unspecified Anemia and Blood Disease

CC 49-50

Dementia or Other Specified Brain Disorders

CC 51-52

Drug/Alcohol Psychosis or Dependence

CC 54-56

Major Psychiatric Disorders

CC 58

Depression

CC 59

Anxiety Disorders

CC 60

Other Psychiatric Disorders

CC 67-69, 100-102, 177-178

Hemiplegia, Paraplegia, Paralysis, Functional Disability

CC 71

Polyneuropathy

CC 77-78

Respirator Dependence/Respiratory Failure

CC 79

Cardio-Respiratory Failure and Shock

CC 80

Congestive Heart Failure

CC 81-82

Acute Coronary Syndrome

CC 83-84

Chronic Atherosclerosis or Angina

CC 89

Hypertensive Heart and Renal Disease or Encephalopathy

CC 92-93

Specified Arrhythmias and Other Heart Rhythm Disorders

CC 94

Other and Unspecified Heart Disease

CC 95-96

Stroke

CC 104-106

Vascular or Circulatory Disease

CC 109

Fibrosis of Lung and Other Chronic Lung Disorder

CC 111-113

Pneumonia

CC 131

Renal Failure

CC 148-149

Decubitus Ulcer or Chronic Skin Ulcer

CC 152

Cellulitis, Local Skin Infection

CC 157

Vertebral Fractures

 

Table D.1.9 – Risk Variables for THA/TKA Readmission Measure

Variable

Description

n/a

Age minus 65 (years above 65, continuous)

n/a

Male

n/a

Index admissions with an elective THA procedure

n/a

Number of procedures (two vs. one)

ICD-9 code 755.63

Skeletal Deformities

ICD-9 code 716.15, 716.16

Post Traumatic Osteoarthritis

ICD-9 code 278.01

Morbid Obesity

CC 1, 3-6

History of Infection

CC 7

Metastatic Cancer or Acute Leukemia

CC 8-12

Cancer

CC 15-20, 119, 120

Diabetes Mellitus (DM) or DM complications

CC 21

Protein-Calorie Malnutrition

CC 22, 23

Disorders of Fluid/Electrolyte/Acid-Base

CC 38

Rheumatoid Arthritis and Inflammatory Connective Tissue Disease

CC 44

Severe Hematological Disorders

CC 49, 50

Dementia or Other Specified Brain Disorders

CC 54-56

Major Psychiatric Disorders

CC 67-69, 100-102, 177-178

Hemiplegia, Paraplegia, Paralysis, Functional Disability

CC 71

Polyneuropathy

CC 80

Congestive Heart Failure

CC 83-84

Coronary Atherosclerosis or Angina

CC 89, 91

Hypertension

CC 92, 93

Specified Arrhythmias and Other Heart Rhythm Disorders

CC 95, 96

Stroke

CC 104-106

Vascular or Circulatory Disease

CC 108

Chronic Obstructive Pulmonary Disease (COPD)

CC 111-113

Pneumonia

CC 130

Dialysis Status

CC 131

Renal Failure

CC 148, 149

Decubitus Ulcer or Chronic Skin Ulcer

CC 152

Cellulitis, Local Skin Infection

CC 162

Other Injures

CC 166

Major Symptoms, Abnormalities

Resources:

H.R. 1343 — 114th Congress: Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015. Retrieved from https://www.govtrack.us/congress/bills/114/hr1343

S. 688 — 114th Congress: Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015. Retrieved from https://www.govtrack.us/congress/bills/114/s688

Congressman Eliot Engel 3/10/15 - Engel and Renacci Introduce Bill to Reform Hospital Readmission Program: http://engel.house.gov/latest-news1/engel-and-renacci-introduce-bill-to-reform-hospital-readmission-program/

Senator Manchin Fact Sheet on Reforming the Affordable Care Act’s Hospital Readmission Program: http://www.manchin.senate.gov/public/index.cfm/files/serve?File_id=ed2ff0cf-f22d-46d3-85cc-09edb545dac0

AHA March 10, 2015 Press Release: http://www.aha.org/presscenter/pressrel/2015/150310-pr-readmissions.shtml

Quality Net Readmissions Measure Methodology Reports:

https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1219069855841

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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