Administrative Memos

200106

FROM: Theodore O. Will, Chief Executive Officer
DATE: Apr 10, 2001
SUBJECT: Aggregate Project Report: Readmission within 30 days to the same hospital
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, Ext. 364
Kathy Terry, Ph.D., Director, Data Analysis & Evaluation, Ext. 261

In the Medicare Sixth Scope of Work, PROs are required to implement coding/DRG payment error prevention projects as well as projects relating to inappropriate/unnecessary admissions. Readmission within thirty days was selected as IPRO's first inappropriate/ unnecessary admission project. Selection of this topic area was based, in part, on an OIG report which identified New York State (NYS) as an area with high readmission rates. The report was released in April, 1999 and entitled "Monitoring Quality of Care and Overpayment Issues Associated with Hospital Readmissions Under the Medicare Prospective Payment System (PPS)".

IPRO's study collected data on readmission pairs focusing on the following four indicators that might lead to an unnecessary readmission:

Hospital failure to ensure that each patient met admission criteria.
Hospital failure to ensure patient stability at discharge on the first admission.
Hospital failure to use pass days appropriately.
Inadequate discharge planning on the first admission.

To conduct IPRO's readmission project, we calculated a readmission rate for each hospital as well as the average NYS Medicare readmission rate based on analysis of CY 1998 Medicare claims data. The NYS Medicare average readmission rate for CY1998 was 12.6%. Hospital-specific readmission rates were then compared to the NYS average to identify outliers. IPRO designated the top 10% of the hospitals, each with a readmission rate ranging from 14.9% to 17.9%, as targeted outliers.

Additionally, IPRO noted that of the 200+ NYS acute care hospitals, 37% were above the NYS average readmission rate of 12.6% for CY 1998. Therefore, in addition to the chart review component of this project, IPRO produced individual hospital-specific reports for each NYS hospital. These reports were previously mailed to all hospitals as PEPP Administrative Memorandum #2000-01 (Hospital Readmission Report) and PEPP Administrative Memorandum #2000-08 (Hospital-Specific Readmission DRG Report Follow-Up), respectively.

As discussed in detail in the enclosed report, although the aggregate error rate for IPRO's Readmission Project is 9.5 %, the majority of the errors are for technical denials due to hospital failure to provide the requested medical records. Errors associated with unnecessary admissions/readmissions errors were minimal in the sample selected for the study, at 0.9%. If your hospital had cases selected for this study, a denial case list is provided as an attachment to this report. As a result of the low error rate associated with this focus area, there will be no additional intervention activities taken by IPRO in regard to this PEPP project at this time.

Should you have any questions in regard to this memorandum or the enclosed report, please feel free to contact Andrea Goldstein or Dr. Kathy Terry.