Please see below for an overview of a report HHSC recently released on Potentially Preventable Readmissions for FY ’12 in Texas Medicaid, as well as the link to the full report. Below that, please see an overview of a report HHSC released on Potentially Preventable Complications for FY ’12 in Texas Medicaid as well as the link to the full report.
Potentially Preventable Readmissions in the Texas Medicaid Population, State Fiscal Year 2012
OVERVIEW
The purpose of this report is to provide data on the volume and rate of PPRs in each Texas and out-of-state hospital that served Texas Medicaid clients during state fiscal year (SFY) 2012.
House Bill (H.B.) 1218, 81st Legislature, First Called Session 2009, requires the Health and Human Services Commission (HHSC) to identify potentially preventable readmissions (PPRs) in the Medicaid population and then confidentially report the results to each hospital annually. The law also requires each hospital to distribute the information to its care providers.
Senate Bill (S.B.) 7, 82nd Legislature, First Called Session 2011, requires HHSC to implement quality-based payments to hospitals on the basis of the results of PPR analysis.
This is the fourth year for which PPR analysis has been performed and reported. Section 2.8 of this document compares the results of SFY 2010, SFY 2011, and SFY 2012. The difference in PPR rates between all three years is virtually unchanged. The SFY 2010 was 3.704, SFY 2011 is 3.678, and SFY 2012 is 3.740.
Section 2 of this report shows that 3.7 percent (Table 2.2.1) of Texas Medicaid inpatient stays in SFY 2012 were followed by at least one PPR within 15 days of discharge. The cost to Medicaid of these PPRs was approximately $111.2 million (Table 2.2.2), or about 3.5 percent of the total Medicaid payments that were made to hospitals. The PPR rate and the percentage of total payments may seem modest in the context of a very large program. The overall rate includes a large volume of obstetric stays, where PPRs were rare (0.8 percent). The non-obstetric pediatric population's PPR rate was 4.1 percent; the non-obstetric adult population's PPR rate was 8.2 percent.
Of the clients who were initially admitted for mental illness or substance abuse, 9.1 percent of pediatrics and 11.4 percent of adults were readmitted within 15 days. Many were readmitted again after the 15 days. PPR rates were even higher for some individual All Patient Refined (APR)-Diagnosis Related Group (DRG)s, ranging as high as 19 percent for Other Hepatobiliaty, Pancreas & Abdominal Procedures.
Many people are familiar with Medicare's approach to calculating and reporting readmission rates. HHSC' s approach differs to more accurately reflect the needs of the Medicaid population. The HHSC approach considers almost all medical conditions, but it only classifies a readmission as potentially preventable if there is a plausible clinical connection between the initial admission and the readmission.
A readmission "window" of 15 days is used, and clients in Medicaid fee-for-service (FFS), Primary Care Case Management (PCCM), and managed care programs are included. The approach uses PPR software that was developed by 3M Health Information Systems. The same approach is being used by other states as mentioned later in this report in more detail in Section 3 and
Appendix B.5.
Not all readmissions are preventable. The methodology for calculating PPR rates attempts to control for and exclude readmissions that were likely planned or were otherwise unavoidable. Nationwide, a high level of readmissions may reflect the absence of appropriate care in our health-care system, especially the manner in which patients are transitioned from the hospital to care in the community or in a post-acute facility.
The hospital, with its central role in every community's health-care system, can play a valuable role in improving that transition. The range of hospital performance is wide enough to suggest that hospitals can learn from each other on how to reduce PPRs (Table 2.6.1.) If the number of PPRs was reduced by 10 percent, the result would be a savings of approximately $11 million a year to the Medicaid budget and, more importantly, improved health and satisfaction among the clients who are served by HHSC and hospitals serving the Medicaid population.
Potentially Preventable Complications in the Texas Medicaid Population, State Fiscal Year 2012
OVERVIEW
The purpose of this report is to provide data on the volume and rate of potentially preventable complications (PPCs) in Texas and out-of-state hospitals that served Texas Medicaid clients during state fiscal year 2012 (September 1, 2011, through August 31, 2012). Clients in Medicaid fee-for-service (FFS), Primary Care Case Management (PCCM), and managed care organization (MCO) delivery models are included in this report. This is the second year for which PPC analysis has been performed and reported.
Senate Bill 7 (S.B.7), 82nd Texas Legislature, First Called Session, 2011, requires the Health and Human Services Commission (HHSC) to identify PPCs in the Medicaid population annually and then confidentially report the results to each hospital. A hospital shall distribute the information contained in the PPC report to physicians and other health-care providers providing services at the hospital. It also requires HHSC to implement quality-based payments that will adjust reimbursements to hospitals based
on the hospital's PPC rate. Quality based payment adjustments that reflect PPC results for SFY 2011 became effective November 1, 2013.
This public report shows statewide PPC results, with no hospital-specific information. Each hospital can obtain its own confidential PPC results through its secure mailbox at www.tmhp.com. This PPC analysis and reports are based on the PPC approach developed by 3M Health Information Systems and previously used to analyze complication rates in the Maryland, California, New York Medicaid, and U.S. Medicare populations. In this report, the approach was used to measure complication rates in the Texas Medicaid adult and obstetric populations. Children and newborns were omitted because the PPC tool is not fully developed for those populations.
The PPC approach takes a broad view of inpatient complications, supplementing the more narrow approaches that focus on "never events" or the Medicare list of hospital acquired conditions (HAC). While the never event and HAC lists include only complications that are always or almost always preventable, the PPC list includes a broad list of almost 1,600 complications that are potentially preventable. Septicemia, pneumonia, kidney failure, and obstetric lacerations, for example, are common inpatient complications that are sometimes preventable and sometimes unpreventable. The PPC approach is to measure a hospital's complication rate against peers that treat patients with similar illnesses.
Section 2 of this report shows that 6 percent of adult stays and 5 percent of obstetric stays included at least one PPC in state fiscal year 2012. Out of327,649 stays, a total of 17,649 stays included at least one PPC. Patients who had at least one PPC were at notable risk for additional PPCs as well. Obstetrical complications were the most common PPC category, while cardiovascular-respiratory complications and infectious complications were the most expensive categories. Overall, PPCs added an estimated $97.4 million, or 3. 7 percent, to the hospital cost of caring for these patients.
Although not all complications are preventable, any reduction in complication rates brings obvious benefits to patients and the healthcare system more generally. Substantial reductions are possible, as has been demonstrated by initiatives in Maryland, Michigan, and elsewhere to reduce infection rates in intensive care units.
In measuring hospital performance, it is essential to reflect the reality that some patients are at much higher risk of complications than others. This analysis compares the actual incidence of each of 65 PPCs with the incidence that would be expected for a hospital with the same patient case mix. Excluding low volume hospitals, 39 percent of hospitals performed lower than expected while 29 percent performed higher than expected; the remaining 32 percent were about as expected (see Table 2.4.1 of the report). The wide range in performance implies that hospitals can learn from each other in reducing complication rates.
This PPC report reflects the commission's work and increasing emphasis on quality, efficiency, and initiatives to invest in quality and outcome-based reimbursements within Medicaid and CHIP. See, for example, the PPC report for SFY 2011 and similar analyses of potentially preventable readmissions. A sustained data-driven focus on the measurement and public reporting of healthcare quality indicators promotes transparency, accountability and efficiency of the healthcare system. HHSC has a number of initiatives underway, including those using data collection and analysis and payments based on potentially preventable events, such as PPCs.