Cooperating for better care.

National Quality Forum

Tag Archives

Mo. hospitals focus on patient poverty in CMS readmissions penalties

revolving door



For Kaiser Health News

Christian Hospital says its costly difference of opinion with Medicare hinges on how to count the large number of poor people that the St. Louis hospital treats.

Medicare penalizes hospitals that readmit too many patients within 30 days of discharge, and Christian expects to lose almost $600,000 in reimbursements this year, hospital officials said. Christian is one of 14 hospitals in the BJC HealthCare System.

Steven Lipstein, chief executive of BJC, which includes Barnes-Jewish Hospital in St. Louis, said Medicare doesn’t play fair because its formula for setting penalties does not factor in patients with socioeconomic disadvantages — low-income, poor health habits and chronic illnesses for instance — that contribute to repeated hospitalizations.

If Medicare did that, Christian’s penalty would have been $140,000, Lipstein said.

As every hospital executive knows, half a million dollars pays for “a whole lot of nurses.”

In total, hospitals around the country lost $420 million last year under Medicare’s Hospital Readmissions Reduction Program, an initiative of the federal health law that seeks to push hospitals to deliver better patient care.

Since the program began in 2012, “recent trends in readmissions suggest that (it) is having the desired impact,” Health Affairs reported in January.

Hospitals have lobbied Congress and Medicare to change the rules and gained some ground May 18 when Rep. Patrick Tiberi, R-Ohio, introduced a bill in the House to adjust Medicare’s program to account for socioeconomic status. The bill was co-sponsored by Rep. Jim McDermott,  D.-Wash.

Meanwhile, the Missouri Hospital Association is trying to pull public opinion behind it.

This year, the association overhauled its consumer Web site, Focus On Hospitals, to include not only the federal readmissions data, but also each member’s readmissions statistics, adjusted for patients’ Medicaid status and neighborhood poverty rates.

The federal government already adjusts its readmissions data for age, past medical history and other diseases or conditions, and that’s public on Medicare’s Hospital Compare Web site.

The association explains its adjustment methodology in an article on the site. “There is emerging national research that suggest poverty and other community factors increase the likelihood a patient will have an unplanned admission to the hospital within 30 days of discharge,” it states.

The hospital group’s alternative data — Lipstein’s source for how Christian could have reduced its 2015 penalty — comes from a study it commissioned. One finding: Missouri hospitals’ readmissions rates improved by 43 to 88 percent when patients’ poverty levels were considered.

“The question is, has [readjustment] been done in a just and fair way,” Lipstein said. The Missouri Hospital Association “has provided methodology that suggests what the Feds are doing is unfair.”

The controversy over penalties is likely to grow beyond the readmissions question. Federal health officials have announced that they want to shift from paying doctors and hospitals based on the services they provide and move toward a value-based system that encourages a better quality of care and better outcomes while controlling costs.

Medicare bases penalties on readmissions on the care of Medicare patients who were originally hospitalized for one of these five conditions — heart attacks, heart failure, pneumonia, chronic lung problems and elective hip or knee replacements.

This year, Medicare penalized almost half of all hospitals — 2,592 to be exact — for excessive readmissions. More than 500 were fined 1 percent of their Medicare payments, or more, for the fiscal year that will end Sept. 30.

Still, the system harms so-called safety-net hospitals most, said Herb Kuhn, the Missouri Hospital Association’s president.

“Hospitals in difficult neighborhoods are getting worse scores, and those in affluent [ones] are getting better. It’s time to adjust [rates] for the disease of poverty,” he said.

Kuhn’s experience makes him an influential voice on health-policy issues. He was deputy administrator of the Centers for Medicare & Medicaid Services from 2006 to 2009 and before that, director of the agency’s Center for Medicare Management. In April, Kuhn completed a three-year term on the Medicare Payment Advisory Commission, which advises Congress.

The commission proposed an alternative to Medicare’s readmission penalties last year. Others are also studying modifications.

The Centers for Medicare & Medicaid Services has taken a cautious stance, but last year CMS announced it is working with the National Quality Forum, a nonprofit group whose research influences CMS’s quality metrics, on a trial to test socioeconomic risk adjustment.

But Leah Binder, CEO of the Leapfrog Group, a nonprofit patient safety group, says Medicare’s readmission penalties have pushed hospitals to improve care and adjusting the data for patients’ poverty levels could deter them.

“Hospitals are paid a lot of money. I think they can find a way to handle their readmissions, the way they should have been handling them all along,” Binder said.

Aetna official explains success of quality benchmarks


Andrew Baskin, M.D., Aetna’s national medical director, explains to FierceHealthPayer how the Core Quality Measure Collaborative’s  standardized set of quality benchmarks were achieved.

For one, the Centers for Medicare & Medicaid Services, America’s Health Insurance Plans and the National Quality Forum took a unique approach to developing the measures.

The news service paraphrased him as saying that said that  the  group began by creating measures “that served as a starting point, then in stages brought in representatives from the provider community, followed by purchasers and consumers, all of which contributed to designing the final sets of measures.”

He said that “one of the problems in the past has been when you put them all at the table right from the very beginning, it’s real hard to make progress.”

“The idea of bringing in the different stakeholders at stages–while some may have criticized that, saying everyone should have been at the table in the beginning–in reality I think it was one of the reasons that this was able to be successful.”

Dr. Baskin said that the other primary reason why this recent effort worked was the  rise of concepts such as value-based care, bundled payments and Accountable Care Organizations, all of which all require better quality measurement.

But, he cautioned, while introducing core measure sets is a positive step, many specialty practice areas still need their own quality benchmarks, and as more measures are developed for sets that are now “perhaps too small,” those must be added to the current sets.

CMS ratings said to lack key socio-economic data


The groups says that Medicare’s five-star scale that rates the quality of care doesn’t offer a complete picture because it fails to reflect these distinct  factors.

One way to address the problem, the groups say, is for CMS to add  income-related information into its ranking calculations. The star-rating system currently uses patient-satisfaction data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to determine the scores.

Beth Feldpush, senior vice president for policy and advocacy for America’s Essential Hospitals, told CMS that research warns  that larger hospitals, teaching hospitals and hospitals serving many low-income patients could well receive lower star ratings even though they provide quality care to the most vulnerable populations. She also complains  the system  oversimplifies complex and individualized choices that patients must make about their health.

She urged the agency to use  measures endorsed by the National Quality Forum that clearly  account for these socio-economic and demographic factors.


Better but fewer metrics, please


Christine Cassel, M.D., president and chief executive of the National Quality Forum, said the healthcare-quality movement’s biggest challenge is to “reduce the noise and increase the signal strength” of measures  to assess  individual hospitals and healthcare systems. She said that healthcare has gone from having too few quality measures to having too many.

Given that, as well as the accelerating  shift to value-based payment models, “it is even more important that we get the measures right,” she said.

Dr. Cassel said that is that many metrics need more science behind them.

Her biggest goals for the NQF, as reported in FierceHealthcare:

  • “Align quality measures among all payers.
  • “Identify more actionable, meaningful measures.
  • Achieve greater consistency and rigor with consumer information.
  • “Leverage new technology and big data to identify and assess quality metrics.
  • “Make sure measure reflect actual clinical quality, not factors like socioeconomic status that are out of health systems’ control.
  • “Attribute results to specific providers.
  • “Improve consumer engagement. ”


New ambulatory vs. critical-care confusions


A look at the usefulness and reality of new federal quality and safety benchmarks this year, which are not leaving everyone happy.

Consider that, as Hospitals & Health Networks reports, a “major shift is taking place in Medicare’s Physician Quality Reporting System program, while the National Quality Forum is examining a group of relatively unpopular patient-safety measures for possible revision.”

”{S}ome physicians — including specialists who work in ambulatory care — continue to be concerned that they will have a difficult time finding measures that realistically can be met.

”Some of the worry is driven by changes to the measures that can be used in PQRS reporting. Emergency department physicians face a limited number of choices that can be applied to their specialty. ”

H&HN said that Catherine Polera, chief medical officer for the emergency medicine division of Sheridan Healthcare, noted that ”the Centers for Medicare & Medicaid Services removed some of the core measures that may have worked in an emergency department setting and replaced them with ambulatory care measures. The new measures ‘relate more to primary care than they do critical care.’

”Although primary-care measures have some application to the ED, ‘we see more trauma, we see more chest pain patients, more abdominal pain patients, and I’m not seeing those related measures,’ she says.”

‘”Determining the implications for a hospital is a little more complicated,” Akin Demehin, senior associate director of policy for the American Hospital Association (AHA), told H&HN {which is part of the AHA}. “‘It mainly boils down to whether a physician bills for the procedure or whether the hospital bills for the physician. Whoever submits the bill, generally speaking, is going to be responsible for the reporting.”’



Contact Info

(617) 230-4965

Wellesley, Mass