Hospital Responses to Medicare Readmission Penalties

 描述（由申请人提供）：早期再入院（30天内再入院）是常见的，昂贵的和潜在的预防。2003年和2004年，18%到20%的医疗保险受益人出院后30天内再次入院，医疗保险计划每年的费用估计为170亿美元。已经测试了各种减少再入院的干预措施，结果好坏参半。在2013财年，CMS开始评估对充血性心力衰竭（CHF）、急性心肌梗死（AMI）和肺炎（PN）的计划外再入院率超过其患者人群在医院再入院减少计划（HRRP）下预期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。在医院报销的经济处罚的新奇，沿着其规模和范围，使HRRP的影响调查的关键优先事项。因此，我们提出以下问题：Q1：哪些医院受到处罚，他们的再入院率如何随着时间的推移而变化？使用描述性，分层分析，我们将研究随着时间的推移，各种类型的医院，包括那些高，低和没有惩罚，那些服务于大量低收入和/或少数民族人口，安全网和财政困难的医院的处罚和再入院率。描述性分析将为后续分析提供背景，并及时提供关于是否以及如何改变政策的明确信息。问题2：HRRP对该计划所针对的Medicare再入院率有何影响？使用分层广义线性模型，患者，医院和市场特征影响特定条件的再入院率，我们将检查政策变化前后的再入院率。我们的主要关注点是CHF、AMI和PN，其次关注2015财年针对的新疾病：慢性阻塞性肺疾病、冠状动脉旁路移植术和经皮冠状动脉介入治疗。问题3：我们是否观察到HRRP对其他再入院率的溢出效应？如果医院发现将医疗保险CHF/AMI/PN患者与其他患者区别对待是不道德的、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HRRP所涵盖的类似条件的再入院和相同条件的非医疗保险再入院中寻找这些。为了比较，我们还将研究痴呆和背痛的再入院，这两种临床上不相关的疾病不在HRRP范围内。 使用2010-2014年卫生保健利用项目（HCUP）国家住院病人数据库，从9个州，公开报道的处罚，美国医院协会年度调查的医院数据，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，因为它们比医疗保险索赔更早发布，并且包括非医疗保险患者。我们的描述性和多变量相结合的方法有利于及时的政策导向的出版物（Q1）和严格评估HRRP对医疗保险和非医疗保险人群（Q2和Q3）的目标和非目标再入院的影响。

 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).