Recent Developments in the Analysis of Admissions Data Jon Bumbaugh and Christie Teigland the Thirteenth Population Health & Care Coordination Colloquium

Recent Developments in the Analysis of Admissions Data Jon Bumbaugh and Christie Teigland The Thirteenth Population Health & Care Coordination Colloquium

March 13‐15, 2013 Discussion Objectives

• Introduction

• Focus on Hospital Readmission Rates: Background

• Hospital Readmission Measure Methodologies

• Medicare Advantage Data Available from the MORE² Registry®

• Update on Medicare Advantage Hospital Readmission Rates

• Comparing Methodologies for Readmission Measures Currently in Use

• National Quality Forum Request for NCQA and Yale to “Harmonize” Measures

• The Debate Regarding Readmission Measure Definitions Continues….

• Origins: 1998 • Headquarters: Outside Washington, D.C. • Employees: Approximately 1,500 office‐based

personnel, and thousands of in‐community

clinical and operations personnel • Clients: – Hundreds of Health Plans

– Integrated Healthcare Delivery Systems

– Regulatory Organizations

– Academic Institutions

– Physician Associations

– Pharmaceutical Companies

• Adoption: Solutions touch more than: – 120 Million Members;

– 540,000 Physicians; and

– 220,000 Clinical Facilities in

– 99% of all U.S. Counties.

• Empowered: Leveraging the data insights of

more than 6 billion medical events

Inovalon has compiled healthcare datasets which are among the most extensive and

broadly representative in the marketplace.

The MORE² Registry contains de‐identified health data for:

9More than 6.3 billion medical events, 9541,000 physicians, 9220,000 clinical facilities, and 986 million unique members 9All payer types: Commercial, Medicare, Medicaid

® MORE² Registry

Sample Counts: Patient Disease Groups through 2012 Alzheimer’s Disease/Dementia: 1,019,996 Hepatitis B: 251,818 Anemia: 9,386,721 Hepatitis C: 538,785 Anxiety: 6,202,332 HIV: 342,527 Asthma: 8,397,075 HPV: 670,625 Atrial Fibrillation: 2,048,651 Lung Cancer: 351,634 All Cancers: 4,513,604 Macular Degeneration: 1,123,542 Bipolar Disorder: 1,199,786 Multiple Sclerosis: 197,580 Breast Cancer: 851,900 Myocardial Infarction: 1,579,195 Cardiovascular disease: 5,744,520 Prostate Cancer: 769,664 Colon / Colorectal Cancer: 445,971 Psoriasis: 769,664 COPD: 4,448,365 Pulmonary Embolism: 382,726 Diabetes –Type I: 1,682,736 Rheumatoid Arthritis: 947,547 Diabetes –Type II: 7,882,106 Schizophrenia: 464,579 Depression: 6,481,150 Stroke – Hemorrhagic: 199,832

Dyslipidemia: 17,581,747 Stroke –Ischemic: 966,029

Background: • Hospital readmissions are receiving increasing attention as a largely avoidable source

of poor quality care and excessive spending. • In April 2009, a study on readmissions within Medicare’s fee‐for‐service (FFS)

program found a 19.6% 30‐day readmission rate in 2004.1

• Although studies have shown that specific interventions—particularly for patients

with multiple conditions—reduce readmission rates by up to 50%, CMS found that

Medicare’s national 30‐day readmission rate did not change appreciably between

2004 and 2009.2 • In 2010, the readmission rate for Medicare beneficiaries remained flat at 19.2%.3

– Just under 10 million admissions

– Approximately 1.9 million readmissions

– Cost estimated to exceed $17 billion (inpatient spending)

1 Jencks SF, Williams MV, and Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. NEJM 2009; 360: 1418‐28. 2 Berenson R, Paulus R, Kalman N, Medicare’s Readmissions‐Reduction Program—A Positive Alternative, NEJM, 2012; 366;15.

3 National Medicare Readmission Findings: Recent Data and Trends, Office of Information Products and Data Analytics, CMS presentation.

Background: • The Patient Protection and Affordable Care Act requires Medicare to penalize

hospitals starting October 2012 by adjusting DRG payments for high readmission

rates (i.e., “worse than expected”) related to myocardial infarction, pneumonia, or

heart failure.4 – Penalties of up to 1% were charged to 2,211 hospitals in the first year.

– Penalties will rise to up to 2% in FY 2014 and up to 3% in FY 2015.

– Beginning FY 2015, CMS plans to expand the program to include readmissions for other

common diagnoses. – Hospital readmission rates are publicly reported as a measure of quality.

• Crediting this program, CMS reported the first observed decrease in the rate of re‐

hospitalizations in the final quarter of 2012.5 – After fluctuating between 18.5% and 19.5% from 2007 to 2011, the 30‐day all cause

readmission rate dropped to 17.8% in 2012.

4 medicareadvocacy.org http://www.medicareadvocacy.org/2012/05/02/medicare‐hospital‐readmissions/ accessed on 9/18/2012

5 http://www.healthleadersmedia. com/print/HEP-28972130Day-Readmission-Rates-Fell-in-2012 accessed on 3/1/2013

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 7 ©2013 by Inovalon, Inc. All rights reserved. Medicare Advantage (MA) Hospital Readmission ® Rates Using Inovalon’s MORE² Registry An Inovalon study based on 2.4 million individuals drawn from 11 representative MA

health plans published in AJMC in 2012 found the 30‐day readmission rate was about

14.5% annually during the 2006‐2008 period—approximately 26% lower than the

19.6% FFS rate reported by Jencks.6

Cumulative Patients at Risk Readmissions Percent at Beginning of 0‐30 Days After Readmitted Period Discharge FFS (Jencks et al) 2004 2,961,460 579,903 19.6%

MA 2006 62,012 9,069 14.6%

2007 75,847 11,013 14.5% 2008 93,226 13,559 14.5%

*In all years, rates were significantly (p<.001) less than the Medicare FFS rate.

6Lemieux M, Sennett C, Wang R, Mulligan T, Bumbaugh J. Hospital Readmission Rates in Medicare Advantage Plans, Am J Managed Care. 2012;18(2):96‐104

Different definitions of “number” of readmissions and “number” of discharges and

other methodological differences result in a divergence of rates across various

measures currently in use. Considerations:

1. How is the universe of patients defined?

2. What types of cases are excluded from index admissions?

3. What types of cases are excluded from countable re‐hospitalizations?

• e.g., does the definition distinguish and exclude planned surgical, medical or

other planned admits? 4. What risk‐adjustment methodology is used?

5. How are multiple readmissions for same patient counted?

6. Are only clinically related admissions considered?

Jencks definition: •Defines a hospital readmission as an admission to a hospital within 30 days after

discharge following an original (index) admission and discharge. Numerator = number of re‐hospitalizations

Denominator = number of index discharges in given period of time

― Calculates rates over a 12‐month period for the cohort discharged during last quarter of

given year (October 1 through December 31 in prior year). ― Counts only the first readmission for each discharge. ― Excludes patients who were transferred on day of discharge to another acute care hospital.

― Excludes patients re‐hospitalized for rehabilitation within 30 days after discharge.

― Excludes data for patient if death occurred.

(Note: at the health plan level, disenrollment from the plan is also a censoring event)

As of January 2013, approximately 14 million Medicare beneficiaries were enrolled • in a Medicare Advantage (MA) health plan.7

MA plans have substantial flexibility to arrange coverage and develop networks of • health care providers to serve their enrollees.

Most MA plans are local health maintenance organizations (HMOs), also called • coordinated care plans (CCPs) or regional preferred provider networks (PPOs).

Because MA plans are paid on a capitated basis (a fixed, risk‐adjusted amount per • enrollee), they have added incentive to attempt to reduce costly avoidable

hospitalizations and readmissions via case management or network contracting

arrangements.

7 Centers for Medicare and Medicaid Services (CMS), Monthly Enrollment by Contract (January 2013). Includes COST, PACE and DEMO enrollees. Data download available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics- Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-Enrollment-by-Contract-Items/Enrollment-by-Contract-2013-01.html

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 11 ©2013 by Inovalon, Inc. All rights reserved. Update on Medicare Advantage Hospital ® Readmission Rates Using the MORE² Registry Where is the MA 30‐day readmissions rate now? Inovalon updated the earlier study using the MORE² Registry® to see if rates have

improved since 2008 when CMS began targeting readmission rates.

Population Characteristics 2008 2009 2010 2011

Unique members 6,183,167 6,685,043 6,332,116 5,015,060

Average membership 4,802,403 4,946,185 4,636,511 3,409,665

Member months 57,628,839 59,354,216 55,638,138 40,915,978

Members with at least one discharge 802,123 812,694 679,457 491,378 Percentage of members with at least one 14.6% 14.5% 12.9% 11.5% discharge Number of discharges 1,323,496 1,284,362 1,052,595 733,948 Annual discharge rate per 1,000 276 260 227 215 members Number of hospital days 7,739,633 7,864,821 6,449,788 4,508,464

Average length of hospital stay 5.8 6.1 6.1 6.1

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 12 ©2013 by Inovalon, Inc. All rights reserved. Medicare Advantage Plan Demographics MORE² ® Registry − Age Distribution Age distributions are similar and stable across years.

MORE2 Registry® (Medicare Advantage) CMS Denominator File 5% Sample

(Medicare Advantage)

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 13 ©2013 by Inovalon, Inc. All rights reserved. Medicare Advantage Plan Demographics MORE² ® Registry − Gender Distribution Gender distributions are similar and stable across years.

CMS Denominator File 5% Sample MORE2 (Medicare Advantage) (Medicare Advantage)

• Geographic distributions are similar and stable across years. • MORE2 Registry® sample has slightly larger representation in Northeast and slightly

lower representation in the South and West.

MORE2 Registry® vs. CMS Denominator File 5% Sample

Medicare Advantage Members

Census Region 2008 2009 2010 2011

MORE2 MA 5% MORE2 MA 5% MORE2 MA 5% MORE2 MA 5%

Northeast 21.8% 21.2% 26.1% 21.0% 24.7% 20.7% 26.2% 20.4%

Midwest 21.9% 17.8% 23.4% 18.1% 20.8% 17.6% 22.5% 18.4%

South 34.9% 28.6% 28.6% 29.5% 30.9% 30.2% 26.2% 29.6%

West 19.5% 28.2% 19.9% 27.3% 21.5% 27.1% 22.1% 27.1%

US Territory 1.9% 4.2% 2.0% 4.1% 2.1% 4.3% 3.0% 4.6%

Year

• Starting in 2009, we see the first signs of the rate declining, dropping to 13.8% in 2011.

• Medicare Advantage plans demonstrated reductions in readmission rates years sooner than the

first sign of decline in Medicare Fee‐for‐Service (FFS) plans noted in 2012.

• The 31 –60 day readmission rates decline even more from 2008 to 2011.

• And an even larger decline in the 60 ‐ 90 day readmission rates.

Table 1. 2011 Rehospitalizations after Discharge from the Hospital among Patients in

Medicare Advantage Programs Cumulative Cumulative Patients at Cumulative Disenrollmen Interval Death w/o Risk at Readmission t w/o after % % Readmission % % Beginning of s by End of Readmission Discharge by End of Period Period by End of Period Period 0‐30 days 186,839 100.0% 25,789 13.8% 4,103 2.2% 13,170 7.0%

31‐60 days 143,777 77.0% 37,488 20.1% 5,247 2.8% 26,517 14.2%

61‐90 days 117,587 62.9% 44,851 24.0% 5,928 3.2% 36,413 19.5%

– CMS Hospital Readmission Measures

Reported On CMS Hospital Compare – NCQA Plan All Cause Readmission Measure

Used In CMS Five Star Rating System

Four categories of readmissions:8

1.Related and Unplanned. Readmissions that are related to index admission but not planned. For

example, a person readmitted to address an adverse event caused by an infection or sepsis, or a

person with heart failure who is readmitted for chest pain.

2.Related and Planned. Readmissions that are related to the initial hospitalization and are

scheduled in advance to deliver follow‐up care and/or perform medical procedures. For example, a

patient may be admitted for heart failure and readmitted later for the placement of a cardiac stent.

3.Unrelated and Planned. Readmissions that are unrelated and planned. For example, an

admission for chronic obstructive pulmonary disorder (COPD) followed by a readmission for a

scheduled hip replacement surgery.

4.Unrelated and Unplanned. Readmissions that are unrelated to the initial hospitalization and also

unplanned. For example, readmissions for burns or traumas caused by accidents. Another example

might be an initial admission for a gastrointestinal disorder followed by a readmission for skin

cancer.

8 Stephen F. Jencks, M.D., M.P.H., “Rehospitalization: Understanding the Challenge,” Presentation at the National Medicare Readmissions Summit, Washington, DC, June 1, 2009.

9 Horwitz L, et al, Hospital-Wide All-Cause Unplanned Readmission Measure, Final Technical Report, Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, Submitted to CMS, July 2012.

• All three condition‐specific hospital measures exclude certain events:

― Patients who die during the initial hospitalization. ― Same day readmissions to same hospital for same condition. ― Patients who are transferred out of the hospital to another acute care facility. ― Patients who are discharged against medical advice. ― Specific planned admissions (e.g., amputations, hip replacement, mastectomy, kidney

transplant, other organ transplant).9

• Only the AMI measure excludes certain planned follow‐up procedures. The AMI

measure also excludes patients who are discharged on same day of admission.

• CMS did not exclude any “planned” readmissions for heart failure or pneumonia

because “clinical experts who were consulted did not identify common follow‐up

causes for a scheduled procedure that would represent continuing treatment care for

these conditions.”

9 See Horwitz L, et al, Hospital-Wide All-Cause Unplanned Readmission Measure, Final Technical Report, p. 13-14 for full list of conditions considered planned.

Debate on Related vs. Unrelated Readmissions

• CMS’ position is that determining whether the readmission is related to the original admission

cannot be made solely on the basis of the admitting diagnosis for the readmission. 10 Arguments:

― Limiting readmissions to particular diagnoses would permit a hospital to avoid countable

readmissions by changing coding practices. ― It could also create an incentive to avoid patients with conditions that are part of readmission

measures. ― Re‐hospitalizations that are not related to the original admission should not affect some

hospitals disproportionately—similar patients should have same probability of readmission.

• Hospital advocates maintain the small set of existing excluded readmissions does not meet the

statutory requirement that unrelated readmissions not be counted and that hospitals will be

penalized for readmissions beyond their control. ― Recommend excluding patients with conditions such as trauma, burns, substance abuse and

psychiatric disorders. ― Recommend adding a claims modifier so a hospital can identify planned readmissions.

10 Federal Register, August 18, 2011, vol. 76, no 160, p. 51669.

The measures use the hierarchical generalized linear model approach.

• This technique accounts for the clustering of patients within hospitals based

on the assumption that an individual hospital will provide similar quality of

care across patients within its patient population, which can be measured

using hospital‐specific intercepts.11 • The hospital‐specific intercepts account for the non‐independence of

patients within the same hospital. • If there were no differences among hospitals, after adjusting for patient

risk, the hospital intercepts should be identical across all hospitals. • This approach accounts for variation across hospitals in how sick their

patients are when admitted to the hospital (use of AHRQ chronic condition

categories for risk adjustment) to reveal differences in hospital‐specific

quality.

11 Tilson, S and Hoffman, G, Addressing Medicare Hospital Readmissions, Congressional Research Service, Report for Congress, 7‐5700, R42546, May 25, 2012.

• Measure rate calculation:

̶ The predicted number of readmissions in each hospital is estimated given the same

patient mix and its hospital‐specific intercept. ̶ The expected number of readmissions in each hospital is estimated using its patient

mix and the average of each of the estimated hospital‐specific intercepts. ̶ The excess readmission ratio = predicted number / expected number of

readmissions.

• The ratio is measure of relative performance:

― Hospitals performing better than the average hospital that admitted similar

patients (based on patient risk factors and comorbidities), the ratio will be less than

one. ― Hospitals performing worse than the average hospital after risk adjustment will

have a ratio greater than one.

• NOTE: This methodology is more difficult to explain to the public and other stakeholders who are more familiar

with the approach that uses an observed over expected ratio determined in a logistic regression model (e.g.,

NCQA all cause 30‐day readmission measure).

• NCQA’s measure is used in the FIVE STAR ratings for Medicare Advantage plans and will be factored into the

mandated quality bonus payments under the Affordable Care Act.12 • Uses administrative claims to determine the number and percentage of acute inpatient stays during the

measurement year followed by an acute readmission for any diagnosis within 30 days. • Health plan members 18 years and older.

• Members must have been continuously enrolled in the plan for 365 days prior to the discharge date through

30 days after the discharge date with no more than one gap of 45 days or less within the 365 days prior to

discharge date. • Exclusions include maternity related stays; admission to a long‐term care facility; death during admission or

readmission; admissions with same day discharge date. • Measure covers all types of discharges, not just particular conditions as in hospital measures.

― Index Hospital Stay (IHS): An acute inpatient stay with a discharge on or between January 1 and

December 1 of the measurement year. Acute inpatient stays include general medical and surgical hospital

stays where the patient is discharged to a community setting. ― Index Discharge Date: The IHS discharge date. The index discharge date must occur on or between

January 1 and December 1 of the measurement year. ― Index Readmission Stay: An acute inpatient stay for any diagnosis with an admission date within 30 days

of a previous index discharge date.

12 2012 Insights for Improvement, Reducing Readmissions: Measuring Health Plan Performance, an NCQA Insights for Improvement Publication.

• Measure calculation:

― Numerator: Count of 30‐day readmissions with admission date between January 2 and

December 31 of measurement year ― Denominator: Count of index hospital stays ― Observed rate of readmission = Numerator/Denominator • Risk Adjustment:

― To allow fair comparison among plans, the measure is risk adjusted via indirect

standardization, using predicted probabilities of readmission estimated through logistic

regression. ― Risk adjustment is applied by assigning a weight to each index hospital stay, based on the

presence of surgery, discharge condition, comorbidity, age and gender. The Clinical

Conditions (CC) and HCC categories identify comorbidities and attach weights to each

statistically significant comorbidity by product line (i.e., commercial, Medicare) and age group

(18‐64 and 65 and older). ― Weights were developed separately for each product line using a testing database that

includes members from multiple health plans. ― Expected rate of readmission (adjusted probability of readmission) is rate the plan is

expected to have based on case mix and average health plans across the U.S.

• Observed to Expected Ratio (O / E) is calculated for health plan across all age and

gender groups. ― When the ratio is <1.0, the health plan performed better than expected (as predicted by the

model) ― When the ratio is >1.0, the plan performed worse than expected.

―In 2012, NCQA reported O/E ratios for commercial populations 18‐65 years of age and

for Medicare populations 65 years and older.

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 32 ©2013 by Inovalon, Inc. All rights reserved. National Quality Forum Request for NCQA and Yale to “Harmonize” Readmission Measures

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 33 ©2013 by Inovalon, Inc. All rights reserved. National Quality Forum (NQF) Requests for Yale / NCQA to Harmonize Respective Admission Measures

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 34 ©2013 by Inovalon, Inc. All rights reserved. National Quality Forum (NQF) Requests for Yale / NCQA to Harmonize Respective Admission Measures

Examples of key harmonization items requested by the NQF committee: 4.Allow readmissions to count as index admissions. • NCQA modeled its approach to exclude readmissions as index events based on

prior Yale work on the condition‐specific readmission measures and the standard

used in the literature. • NCQA rationale for approach: The intent of counting readmissions as index

events is to hold hospitals accountable for the total impact of mistakes that lead to

readmission and failure to correct on subsequent readmissions. However, this has

the effect of double‐counting (or more) the impact of comorbid conditions in the

risk model, which may lead to erroneous conclusions about which factors predict

readmission. ― Example: a patient admitted for diabetes is discharged on a new regimen and is not adequately educated on self‐ management. The patient becomes hypoglycemic two days later because of confusion between short and long‐acting insulin and is readmitted and experiences further complications that lead to a chain of < 30‐day readmissions.

Suppose this patient has a diagnosis of COPD recorded in preceding 12 months. Dx will count in the regression model for each hospitalization and strengthen the association between that condition and the readmission.

This additional weighting of comorbid conditions will make it harder to identify new conditions like the hypoglycemia as predictors of readmission and may misdirect hospitals’ and plans’ quality improvement activities.

INV JSPH_RecentDevelopmentsinAnalysisReadmissionsData (03 14 13) v 1 0 0 35 ©2013 by Inovalon, Inc. All rights reserved. National Quality Forum (NQF) Requests for Yale / NCQA to Harmonize Respective Admission Measures

5. Allow readmissions to count as index admissions (continued)

• Yale rationale for counting readmissions as index readmissions:

– Institutions should be held accountable for all readmissions.

– A readmission is a signal that discharge planning may have been inadequate –if further readmissions

are not counted in measure, there is no incentive to prevent them. – Some conditions/diagnoses may be more likely to be readmissions – e.g., infections– if we do not

count as index case we may be excluding some conditions more than others.

• Status: NCQA is developing and testing a modified specification to assess the impact of

counting readmissions as index admissions on plan performance relative to current

specification. If the change results in an improvement and meets scientific acceptability

criteria, NCQA would initiate the process to implement the change.

March 6, 2013: Joynt K, Jha A, “A Path Forward on

Medicare Readmissions.” New England Journal of Medicine,

Perspective.

•Cite overwhelming evidence two groups of patients are at particularly high

risk for readmissions: ― those who have the most severe illnesses (because of their underlying

condition); ― those who are socioeconomically disadvantaged.

•The current measure does not account for these factors, leaving hospitals

that disproportionately care for the sickest and poorest patients at greatest

risk for penalties.

•CMS data shows that two thirds of eligible U.S. hospitals were found to have

readmission rates higher than the CMS models predicted, and each of these

hospitals will receive a penalty.

•This is much higher than anticipated on the basis of CMS's previous public

reports, which identified less than 5% of hospitals as outliers.

• Evidence that safety net institutions and large

teaching hospitals are far more likely to be penalized.

• The program has potential to exacerbate disparities in

care and create disincentives to providing care for very

ill patients with complex health needs.

Recommendations:

1. Adjust readmission rates for socioeconomic status

2. Weighting the penalties based on timing of

readmissions • readmissions within first few days after discharge

may reflect poor care coordination or inadequate

discharge planning (weight heavy) • readmissions 4 weeks later are far more likely to be

due to the underlying severity of disease (weight far

less)

3. Give hospitals credit for low mortality rates (based on the

fact these hospitals tend to have higher rates of

readmission and get penalized more than hospitals with

high mortality rates).