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Chronically Critically Ill Population Payment Recommendations (CCIP-PR)

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Chronically Critically Ill Population Payment Recommendations (CCIP-PR) March 2014 Chronically Critically Ill Population Payment Recommendations (CCIP-PR) Final Report Prepared for Shannon Flood Centers for Medicare & Medicaid Services Center for Medicare & Medicaid Innovation 7500 Security Boulevard Baltimore, MD 21244-1850 Prepared by Amy Kandilov, RTI International Melvin Ingber, RTI International Melissa Morley, RTI International Nicole Coomer, RTI International Kathleen Dalton, formerly of RTI International Barbara Gage, Brookings Institution Christina Superina, Kennell and Associates David Kennell, Kennell and Associates Contact: RTI International 3040 East Cornwallis Road Research Triangle Park, NC 27709 RTI Project Number 0212355.000.010 CHRONICALLY CRITICALLY ILL POPULATION PAYMENT RECOMMENDATIONS (CCIP-PR) by Amy Kandilov, Melvin Ingber, Melissa Morley, Nicole Coomer, Kathleen Dalton, Barbara Gage, Christina Superina, and David Kennell Melvin Ingber, Project Director Federal Project Officer: Shannon Flood Kennell and Associates, Inc. and its subcontractor RTI International CMS Contract No. HHSM-500-2006-00081 March 2014 This project was funded by the Centers for Medicare & Medicaid Services under contract no. 500-00-1234. The statements contained in this report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. RTI assumes responsibility for the accuracy and completeness of the information contained in this report. _________________________________ RTI International is a trade name of Research Triangle Institute. CONTENTS EXECUTIVE SUMMARY .............................................................................................................1 SECTION 1 DEFINING THE CCI/MC POPULATION ........................................................21 1.1 Purpose of the Project ..................................................................................................21 1.2 The CCI/MC Population ..............................................................................................21 1.3 Development of a Set of Criteria to Evaluate the Success of the Definitions .............27 1.4 Process of Developing the CCI/MC Definition ...........................................................28 SECTION 2 CHARACTERISTICS OF THE CCI/MC PATIENT IN ACUTE CARE HOSPITAL AND LTCH SETTINGS .................................................................................67 2.1 Overview ......................................................................................................................67 2.2 The CCI/MC in Acute Care Hospitals .........................................................................68 2.3 The CCI/MC in LTCHs ...............................................................................................85 2.4 Readmission/Deaths Among the CCI/MC ...................................................................90 2.5 The Non-CCI/MC in LTCHs .....................................................................................110 2.6 Conclusion .................................................................................................................112 SECTION 3 SIMULATIONS OF THE EFFECT OF THE ALTERNATIVE CCI/MC LTCH PAYMENT MODEL ON LTCH PAYMENTS, MARGINS, AND DISCHARGES ...................................................................................................................113 3.1 Introduction ................................................................................................................113 3.2 Methodology for Static Simulations ..........................................................................113 3.3 Facility-Level Results of the Static Simulations ........................................................115 3.4 MS-LTC-DRG Level Results ....................................................................................124 3.5 Behavioral Simulations of the Alternative CCI/MC LTCH Payment Model ............131 3.6 Methodology for Behavioral Simulations ..................................................................132 3.7 LTCH Industry-level Results Under the Behavioral Simulations .............................134 3.8 Facility-level Results Under the Behavioral Simulations ..........................................136 3.9 State-level Results Under the Behavioral Simulations ..............................................139 3.10 Conclusions and Discussion ......................................................................................141 SECTION 4 SIMULATIONS OF THE EFFECT OF THE ALTERNATIVE CCI/MC LTCH PAYMENT MODEL ON ACUTE CARE HOSPITAL PAYMENTS, COSTS, AND MARGINS ..................................................................................................143 4.1 Introduction to Simulations of ACH Charges, Costs, and Payments ........................143 4.2 Methodology for ACH Simulations ...........................................................................143 4.3 Results Across All Acute Care Hospitals ..................................................................147 4.4 ACH Facility-Level Results .......................................................................................151 4.5 Conclusions and Discussion ......................................................................................155 APPENDIX A CCI/MC FINAL DEFINITION ..........................................................................159 APPENDIX B LTCH CLAIMS AND FACILITY SAMPLE SIZES AND EXCLUSION CRITERIA ..........................................................................................................................161 iii APPENDIX C ACH CLAIMS AND FACILITY SAMPLE SIZES AND EXCLUSION CRITERIA ..........................................................................................................................163 BIBLIOGRAPHY/REFERENCES..............................................................................................165 List of Figures ES-1 The CCI/MC have much longer hospital stays than the non-CCI/MC (Percentage distribution of episode days for each group) ....................................................................... 4 ES-2 Resource use measures for discharges meeting the CCI/MC clinical factors, by critical care days ................................................................................................................. 5 ES-3 Discharge destination for the CCI/MC and all discharges, 2010 (percent of ACH discharges to each setting) .................................................................................................. 9 ES-4 CCI/MC LTCH patients were more likely to die in the LTCH or be sent to another hospital upon LTCH discharge, 2010 .................................................................. 12 1-1 Steps used to develop the CCI/MC definition .................................................................. 29 1-2 Median number of episode days for the restrictive CCI/MC definition and for episodes added under the inclusive definition, by clinical condition ............................... 36 1-3 Distribution of inpatient lengths of stay, by CCI/MC status (percentage distribution of episode days for each group) ..................................................................... 37 1-4 Median Medicare ACH + LTCH payments for the restrictive CCI/MC and for episodes added under the inclusive definition, by clinical condition ............................... 38 1-5 Overlap of Episodes for the Inclusive CCI/MC Population with all MedPAR Inpatient Episodes Over 30 Days ...................................................................................... 40 1-6 Median ACH margins for the restrictive CCI/MC definition and for episodes added under the inclusive definition, by clinical condition .............................................. 43 1-7 Acute care hospital and LTCH margins for restrictive CCI/MC tracheostomy patients .............................................................................................................................. 45 1-8 Acute care hospital and LTCH margins for restrictive CCI/MC prolonged mechanical ventilation patients ......................................................................................... 46 1-9 Acute care hospital and LTCH margins for restrictive multiple organ failure CCI/MC patients ............................................................................................................... 47 1-10 Acute care hospital and LTCH margins for restrictive CCI/MC “sepsis and other” patients .............................................................................................................................. 48 1-11 Acute care hospital and LTCH margins for restrictive CCI/MC wound patients ............. 49 1-12 Acute care hospital and LTCH margins for restrictive CCI/MC constellation of debilitating factor patients ................................................................................................. 50 1-13 Resource use measures for discharges meeting the CCI/MC clinical factors, by critical care days ............................................................................................................... 59 2-1 Number of live CCI/MC discharges from Acute Care Hospitals, by condition, 2010................................................................................................................................... 70 2-2 Discharge destinations from the Acute Care Hospital for the CCI/MC and all discharges, 2010 (percent of acute care hospital discharges to each setting) ..................
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