An Opportunity to Improve Medicare’s Planned Readmissions Measure
In the Hospital Readmission Reduction Program (HRRP), the Centers for Medicare & Medicaid Services (CMS) utilizes a planned/unplanned algorithm to prevent hospitals from being penalized for scheduled rehospitalizations. We evaluated version 3.0 of the CMS planned readmission algorithm and hypothesized that some readmissions categorized as planned by the HRRP algorithm may actually be unplanned. We identified 143,054 index admissions and 16,116 thirty-day readmissions for 131 hospitals. Only 1252 readmissions were considered planned according to Medicare’s readmission algorithm. The majority of these planned readmissions (723 [57.8%]) had an “emergent” or “urgent” admission type listed on the readmission claim, and many (513[41.0%]) had emergency department charges, suggesting unanticipated returns to the hospital. HRRP should consider using the admission type variable and/or the presence of emergency department charges as a source of information when determining whether a readmission is planned or unplanned.
©2017 Society of Hospital Medicine
Readmissions result in $41.3 billion in annual healthcare expenses.1 As a result of the Affordable Care Act, Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Readmission Reduction Program (HRRP) to reduce expenditures and improve quality associated with hospital care.2-5 The HRRP monitors readmission rates for pneumonia, congestive heart failure (CHF), acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG), and joint replacement. Hospitals are penalized for excess readmissions that occur following any of these index admissions. However, some readmissions within 30 days of an index admission are planned. For example, patients may have scheduled admissions for chemotherapy visits or may have prescheduled elective surgeries that happen to fall within a 30-day postdischarge window. Furthermore, even unplanned readmissions may not be a marker of suboptimal care.6 To prevent penalization for planned readmissions, CMS developed an algorithm to exclude planned readmissions from the HRRP.7
Few studies have investigated the planned readmissions in the HRRP since Horwitz and colleagues7 developed the algorithm with the assistance of a technical expert panel and validated it by reviewing charts in 2 healthcare systems comprising 7 hospitals. Most studies focus on unplanned readmissions.8,9 We build on this work by studying readmissions for 131 hospitals and using administrative claims to determine whether the algorithm could be improved. Specifically, we examined planned readmissions after the conditions included in the HRRP and determine whether they occurred under elective, urgent, or emergent circumstances. The goal is to assess whether the algorithm may misclassify some readmissions as planned even though the readmission is unanticipated. We hypothesize that some readmissions considered planned by the HRRP will occur under emergent circumstances. Our findings will provide more nuanced insights regarding planned readmissions and potentially provide a mechanism to identify potentially misclassified readmissions without administrative burden.
METHODS
We analyzed Medicare claims from 2011 to 2015 for beneficiaries in Michigan who had index admissions for pneumonia, CHF, AMI, COPD, CABG, and joint replacement. Exclusion criteria were as follows: patients who were not continuously enrolled in Medicare Part A and B, had health maintenance organization coverage, were transferred to another hospital during the index admission, or received Medicare because of end-stage renal disease or disability. Patients with hip fractures were excluded because the HRRP readmission algorithm only includes elective, unilateral, total hip arthroplasties. Transfer patients were excluded because these patients are excluded from the HRRP readmission algorithm. We also excluded patients who died within 90 days of their index admission because these patients are often outliers in regards to healthcare utilization. The institutional review board at our health system deemed this study exempt from review.
For each hospital and each condition, we calculated 30-day readmission rates by identifying inpatient claims that occurred following discharge from the index admission. For patients who had multiple readmissions, we only considered the first readmission, as this follows the HRRP method. All readmissions were credited to the hospital where the index admission occurred.
To calculate 30-day planned readmission rates, we examined all readmissions and identified those deemed planned by version 3.0 of the CMS readmissions algorithm.10 We characterized these planned readmissions by examining the admission type variable and the presence or absence of emergency department (ED) charges. Planned readmissions that had an admission type of “emergent” or “urgent” and/or ED charges may have been unplanned. Because we cannot unequivocally determine whether or not the readmissions were misclassified, we refer to these readmissions as “potentially misclassified” in this manuscript. We also calculated the potential misclassification rate by hospital type.
