Studies Report Decline in Inpatient Mortality

Mortality rates decreased among patients admitted for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke and pneumonia from 2002 to 2012, according to the Agency for Healthcare Research and Quality (AHRQ). The decline occurred for both men and women, and for Medicare-aged and younger patients.

 

The Journal of the American Medical Association (JAMA) also reported a decline in inpatient mortality for Medicare patients from 1999 to 2013.

 

AHRQ findings included:

  • Mortality decreased most among patients admitted for pneumonia (45 percent decrease). AMI, CHF and stroke decreased by 41, 29 and 27 percent respectively.
  • Inpatient mortality decreases varied by condition and region: the largest decline was among pneumonia patients in hospitals in the Northeast (52 percent); the smallest was 22 percent among stroke patients in the West.
  • Overall inpatient mortality for the four conditions decreased among patients in each major insurance category.
  • Pneumonia: The largest decreases occurred among pneumonia patients covered by Medicare (46 percent) and Medicaid (56 percent) and also among uninsured patients (55 percent).
  • AMI: decreases of 41 percent for Medicare and Medicaid patients.
  • CHF: decrease of 40 percent for Medicaid patients. However, decreases for patients with private insurance or no insurance were not statistically significant.
  • Stroke: decrease of 42 percent for uninsured patients.

 

Decreases Across Income Categories

The AHRQ research also found that:

  • Inpatient mortality rates for the four conditions improved among all income levels. However, some of the largest improvements occurred among the poorest patients for some conditions.
  • Inpatient mortality for pneumonia decreased by nearly half for all income levels, including a 43 percent drop among patients in the poorest communities and a 48 percent decrease in the wealthiest communities.
  • Decreases in CHF and stroke mortality were largest for patients in the poorest communities (34 percent and 30 percent, respectively) and smallest for those in the wealthiest communities (24 percent and 23 percent, respectively).

 

Decreases Across Regions Reported by AHRQ

  • Improvement in inpatient mortality seemed to spread among geographic areas, the largest being among pneumonia patients living in metropolitan areas (47 percent).
  • For AMI, inpatient mortality decreased 41 percent for patients in metro areas, 40 percent in micropolitan areas and 42 percent in rural areas.

 

In addition to studies published by AHRQ and the Journal of the American Medical Association, the Medicare Payment Advisory Commission reported in March that from 2010 through 2013, hospitals had statistically significant improvements in seven of 10 mortality rate measures, comprising in-hospital and 30-day post-discharge mortality for five prevalent clinical conditions. (“Inpatient Mortality Declines Across Payers,” HFMA Weekly News, August 21, 2015)

 

Why the Recent Decline?

Some industry analysts credit the rolling implementation of hospital quality initiatives of the Affordable Care Act for improved hospital patient outcomes in recent years. Other experts “have warned those same programs could begin worsening outcomes for some categories of hospitals by draining resources that are needed to improve care.” (“Inpatient Mortality Declines Across Payers,” HFMA Weekly News, August 21, 2015)

 

 

 

Consumerism: Strategic and Financial Implications, Part Two is in your library now. In this course, Mark Grube (Kaufman Hall), Marian Jennings (M. Jennings Consulting) and Nathan Kaufman (Kaufman Strategic Advisors) discuss organizational characteristics for a retail strategy, the financial implications and “must-do’s” for hospitals and systems. And coming up in late September, part one of Integrating Population Health into Your Strategic and Financial Plans.

 

 

 

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CMS Extends Enforcement Delay of Two-Midnight Rule

Last week the Centers for Medicare and Medicaid Services (CMS) said it will extend the enforcement delay of its two-midnight policy until December 31, 2015. Beginning January 1, 2016, Quality Improvement Organizations (QIOs) and Recovery Audit Contractors (RACs) “will conduct patient status reviews in accordance with any policy changes finalized in the outpatient prospective payment system rule and effective in calendar year 2016.” This rule includes the proposed changes to the two-midnight policy.

 

The proposed changes would allow Medicare Part A reimbursement of short inpatient hospital stays spanning less than two midnights on a “case-by case basis” if the admitting physician documents the medical necessity of the admission. (“CMS Extends Two-Midnight Enforcement Delay Until Year’s End,” AHLA Weekly, August 14, 2015)

 

CMS finalized its inpatient prospective payment system for FY 2016, as reported in last week’s iProtean blog newsletter. We noted that the final rule didn’t extend a partial enforcement delay to the two-midnight rule, even though CMS had published such changes in the proposed outpatient prospective payment system rule for 2016.

 

In its Inpatient Hospital Reviews Update (August 12, 2015), CMS noted that beginning October 1, QIOs will be responsible for conducting inpatient status reviews of providers to determine appropriateness of Part A payment for short stay inpatient hospital claims. Currently, reviews are conducted by Medicare Administrative Contractors. (“CMS Extends Two-Midnight Enforcement Delay Until Year’s End,” AHLA Weekly, August 14, 2015)

 

Beginning in January 2016, RACs may conduct patient status reviews only for those providers that have been referred by the QIO “as exhibiting persistent noncompliance with Medicare payment policies, including, but not limited to: having high denial rates and consistently failing to adhere to the two midnight rule (including repeatedly submitting inappropriate inpatient claims for stays that do not span one midnight), or failing to improve their performance after QIO educational intervention.” (Inpatient Hospital Reviews, Update August 12. 2015, cms.gov)

 

To read the update, click here.

 

Notice of Observation Treatment

Because patient classification as “inpatient” or “under observation” has financial implications for Medicare beneficiaries (e.g., out-of-pocket costs, skilled nursing facility costs), both the United States Senate and House of Representatives unanimously approved the NOTICE Act and President Obama signed it into law on August 6. NOTICE stands for Notice of Observation Treatment and Implication for Care Eligibility.

 

The measure requires hospitals to give individuals who receive observation services for more than 24 hours oral and written notice explaining their status as an outpatient and the implications of that status. (“President Signs Measure Requiring Notice of Observation Status,” AHLA Weekly, August 14, 2015)

 

Hospitals have a year to comply with the new notice requirement.

 

 

 

 

Consumerism: Strategic and Financial Implications, Part Two is in your library now. In this course, Mark Grube (Kaufman Hall), Marian Jennings (M. Jennings Consulting) and Nathan Kaufman (Kaufman Strategic Advisors) discuss organizational characteristics for a retail strategy, the financial implications and “must-do’s” for hospitals and systems.

 

 

 

For a complete list of iProtean courses, click here.

 

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Medicare Hospital Payments Will Increase Less than Expected in 2016

Medicare’s inpatient prospective payments (IPPS) will increase 0.9 percent in fiscal year (FY) 2016, down from the projected 1.1 percent increase noted by CMS in April this year. Capital payments also will increase by 2.3 percent in FY 2016. The final rule was released July 31 and will take effect October 1.

 

According to a CMS fact sheet, “The increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and demonstrate meaningful use of certified electronic health record (EHR) technology . . . reflects the hospital market basket update of 2.4 percent adjusted by -0.5 percentage points for multi-factor productivity and an additional adjustment of -0.2 percentage points in accordance with the Affordable Care Act.” CMS noted that as happened last year, the rate is further decreased by 0.8 percentage points due to an adjustment required by the American Taxpayer Relief Act of 2012. (“Fiscal Year 2016 Final Inpatient and Long-term Care Hospital policy and payment changes,” CMS.gov, July 31, 2015)

 

Quality drove some of the components in the final rule. For example,

  • Hospitals not successfully participating in the IQR Program and not submitting required quality data: a one-fourth reduction of the market basket update
  • Hospitals not a meaningful user of EHR: a one-half reduction of the market basket update
  • Continued penalties for readmissions
  • A -1 percent penalty for hospitals in the worst performing quartile under the Hospital Acquired Condition Reduction Program
  • Continued bonuses and penalties for hospital value-based purchasing

 

 

No Extension of Two-Midnight Rule

 

Enforcement of the two-midnight rule has been repeatedly delayed since it took effect in October 2013.But the final rule doesn’t extend the partial enforcement delay, even though CMS recently published changes to the two-midnight policy in the proposed rule for 2016. (See iProtean blog for July 8, 2015, “Proposed Changes to Two-Midnight Rule Generate Optimism, Praise”).

 

The proposal would allow Medicare Part A reimbursement of short inpatient hospital stays spanning less than two midnights on a “case-by case basis” if the admitting physician documents the medical necessity of the admission. The proposed changes, if finalized, wouldn’t take effect until January 1, 2016. (“Medicare Payments to Hospitals Increase by 0.9% in FY 2016, AHLA Weekly, August 7, 2015)

 

To read the CMS Fact Sheet, click here.

 

 

Consumerism: Strategic and Financial Implications, Part Two is in your library now. In this course, Mark Grube (Kaufman Hall), Marian Jennings (M. Jennings Consulting) and Nathan Kaufman (Kaufman Strategic Advisors) discuss organizational characteristics for a retail strategy, the financial implications and “must-do’s” for hospitals and systems.

 

 

 

For a complete list of iProtean courses, click here.

 

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Study Finds Large Reductions in Medicare Hospitalization and Spending

Authors of a new study speculate that combined improvements in health, patient utilization patterns for health care, and healthcare delivery have dramatically reduced hospital utilization and per-beneficiary spending, while mortality declined among all Medicare fee-for-service enrollees, over the last 15 years. The research was published online in the Journal of the American Medical Association and reported by HFMA Weekly News.

 

The Medicare population grew from 33.5 million in 1999 to 42.4 million in 2013. However, the share of fee-for-service enrollees declined from 82 percent in 1999 to 71 percent in 2013.

 

Key findings for the years 1999 to 2013 for Medicare fee-for-service beneficiaries include:

  • All-cause mortality declined from 5.30 percent to 4.45 percent.
  • In-hospital mortality declined from 1.30 percent to 0.71 percent, 30-day mortality declined from 2.16 percent to 1.65 percent, and one-year mortality declined from 4.49 percent to 3.48 percent.
  • Hospitalizations per 100,000 person-years decreased from 35,273 to 26,930.
  • The number of beneficiaries admitted to the hospital at least once decreased from 21,782 per 100,000 person-years to 17,344.
  • Patients were increasingly discharged to rehabilitation and nursing facilities or with home health care, and decreasingly discharged home without care.
  • Pneumonia dropped from most frequent principle diagnosis for hospitalization in 1999 to fifth place by 2013, replaced by osteoarthritis, septicemia, heart failure and cardiac dysrhythmia.
  • Mean inflation-adjusted inpatient expenditures per beneficiary declined from $3,290 to $2,801.
  • Decrease in hospitalizations translates to more than 3 million hospitalizations averted in 2013 compared with what would have occurred if the rate in 1999 stayed the same.

 

The author of the study noted there was no evidence of this trend leveling out towards the end of 2013.

 

“Hospitals deserve some credit for this trend because of the team focus to rethink care delivery for inpatient admissions and delivery of outpatient care,” the author said. “The gains noted in the study are a result of widespread adoption of standardized processes, measuring and reporting of hospital quality improvement efforts, and prioritizing quality improvements throughout the hospital or health system.” (“Medicare Mortality, Hospitalizations, Spending Decline, Study Says,” HFMA Weekly News, July 31, 2015)

 

Consumerism: Strategic and Financial Implications, Part Two is in your library now. In this course, Mark Grube (Kaufman Hall), Marian Jennings (M. Jennings Consulting) and Nathan Kaufman (Kaufman Strategic Advisors) discuss organizational characteristics for a retail strategy, the financial implications and “must-do’s” for hospitals and systems.

 

 

 

For a complete list of iProtean courses, click here.

 

For more information about iProtean, click here.