Hospital Responses to Medicare Readmission Penalties

 描述(由申请人提供)：早期再次住院(30天内再次住院)很常见，费用高昂，而且可能是可以预防的。在2003年和2004年出院的医疗保险受益人中，有18%到20%的人在30天内重新入院，这使得医疗保险计划每年花费约170亿美元。已经测试了各种减少再次入院的干预措施，结果喜忧参半。2013财年，CMS开始评估对因充血性心力衰竭(CHF)、急性心肌梗死(AMI)和肺炎(PN)的计划外再住院率超过根据医院再入院减少计划(HRRP)对患者群体的预期比率的医院的经济处罚。根据该计划，几乎一半的美国医院面临处罚。医院报销中经济处罚的新颖性，以及它们的规模和范围，使得调查HRRP的影响成为关键优先事项。因此，我们提出以下问题：Q1：哪些医院受到处罚，它们的再住院率随着时间的推移是如何变化的？使用描述性的分层分析，我们将检查不同类型医院随着时间的推移的罚款和再住院率，包括高、低和无罚款的医院，为大量低收入和/或少数群体服务的医院，安全网和陷入财务困境的医院。描述性分析将为后续分析提供背景，并就是否以及如何改变政策提供及时、明确的信息。问题2：HRRP对该计划目标的医疗保险重新住院率有什么影响？使用分级广义线性模型，其中患者、医院和市场特征影响特定条件的再住院率，我们将检查政策变化前后的再入院情况。我们将主要关注CHF、AMI和PN，次要关注2015财年的新目标：慢性阻塞性肺疾病、冠状动脉搭桥术和经皮冠状动脉介入治疗。问题3：我们是否观察到HRRP对其他再入院率有任何溢出效应？如果医院发现以不同于其他患者的方式对待Medicare CHF/AMI/PN患者是不道德的、不切实际的或无利可图的，我们可能会看到溢出效应。我们将在与HRRP覆盖的条件相似的重新入院患者中以及在相同条件的非医疗保险重新入院患者中寻找这些信息。为了进行比较，我们还将研究痴呆症和背部疼痛的再入院情况，这两种临床上无关的疾病不在HRRP的覆盖范围内。使用来自9个州的2010-2014医疗保健利用项目(HCUP)州住院患者数据库、公开报告的罚款、美国医院协会医院年度调查数据、联邦医疗保险医院数据、地区资源文件和人口普查数据，我们将解决研究问题。我们使用HCUP数据，因为它们比联邦医疗保险索赔发布得更早，并且包括非联邦医疗保险患者。我们的描述性和多变量相结合的方法有助于及时发布政策导向的出版物(第一季度)，并严格评估HRRP对联邦医疗保险和非联邦医疗保险人口的定向和非定向再入院的影响(第二季度和第三季度)。

 DESCRIPTION (provided by applicant): Early hospital readmissions (readmission within 30 days) are common, costly and potentially preventable. Between 18 and 20 % of Medicare beneficiaries discharged from a hospital in 2003 and 2004 were readmitted within 30 days, costing the Medicare program an estimated $17 billion annually. A variety of interventions to reduce readmission have been tested, with mixed results. In FY2013, CMS began assessing financial penalties on hospitals with unplanned readmission rates for congestive heart failure (CHF), acute myocardial infarction (AMI) and pneumonia (PN) that exceeded rates expected for their patient population under the Hospital Readmissions Reduction Program (HRRP). Almost half of all U.S. hospitals face penalties under the program. The novelty of financial penalties in hospital reimbursement, along with their size and scope, make investigation of HRRP's impact a critical priority. Thus, we propose the following questions: Q1: Which hospitals are getting penalties and how are their readmission rates changing over time? Using descriptive, stratified analyses, we will examine penalties and readmission rates over time for various types of hospitals, including those with high, low and no penalty, those serving large low-income and/or minority populations, safety net and financially troubled hospitals. Descriptive analyses will provide context for subsequent analyses and timely, clear information about whether and how the policy should be changed. Q2: What is the impact of HRRP on Medicare readmission rates targeted by the program? Using hierarchical generalized linear models where patient, hospital and market characteristics influence condition- specific readmission rates we will examine readmissions before and after the policy change. Our primary focus will be CHF, AMI and PN, with a secondary focus on new conditions targeted in FY 2015: chronic obstructive pulmonary disease, coronary artery bypass graft surgery, and percutaneous coronary interventions. Q3: Do we observe any spillover effects of HRRP on other readmission rates? If hospitals find it unethical, impractical, or unprofitable to treat Medicare CHF/AMI/PN patients differently from other patients, we may see spillover effects. We will look for these among readmissions for similar conditions to those covered by HRRP and among non-Medicare readmissions for the same conditions. For comparison, we will also look at readmissions for dementia and back pain, two clinically unrelated conditions not covered by HRRP. Using 2010-2014 Health Care Utilization Project (HCUP) State Inpatient Databases from 9 states, publicly reported penalties, American Hospital Association Annual Survey of Hospitals data, Medicare hospital data, Area Resource File and Census data, we will address study questions. We use HCUP data since they are released earlier than Medicare claims and include non-Medicare patients. Our combined descriptive and multivariate approach facilitates timely policy-oriented publications (Q1) and rigorous assessment of HRRP's effect on targeted and non-targeted readmissions for Medicare and non-Medicare populations (Q2 and Q3).