Reducing Readmissions after a COPD Exacerbation: A Brief Review

Richard A. Robbins, MD¹

Lewis J. Wesselius, MD²

¹The Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

²Mayo Clinic Arizona

Scottsdale, AZ

Abstract

CMS' Hospital Readmissions Reduction Program (HRRP) was extended to chronic obstructive pulmonary disease (COPD) exacerbations in October 2014. HRRP penalizes hospitals if admissions for COPD exacerbations exceed a higher than expected all-cause 30-day readmission rate. Recently, a review of 191,698 Medicare readmissions after a COPD exacerbation reported that COPD explained only 27.6% of all readmissions. Patients were more likely to be readmitted if they were discharged home without home care, dually enrolled in Medicare and Medicaid, and had more comorbidities (p<0.001 compared to patients not readmitted). Data on interventions is limited but recently a study of bundled interventions of smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48-h postdischarge telephone call did not result in a lower readmission rate. We conclude that there is limited evidence available on readmission risk factors, reasons for readmission and interventions that might reduce readmissions. In the absence of defined, validated interventions it seems likely that CMS's HRRP will be unsuccessful in reducing hospital readmissions after a COPD exacerbation.

Introduction 

To address rising costs and quality concerns, the Hospital Readmissions Reduction Program (HRRP) was enacted, targeting inpatient discharges in the Medicare fee-for-service population for congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia in 2012. HRRP was extended to chronic obstructive pulmonary disease (COPD) exacerbations in October 2014.

Correlation of Readmissions with Outcomes

There were about 800,000 hospitalizations for COPD exacerbations annually, with about 20% of patients needing to be rehospitalized within 30 days of discharge (2,3). The cost of readmissions is about $325 million for the U.S. Centers for Medicare and Medicaid Services (CMS) (4). Therefore, it is hardly surprising that CMS is attempting to reduce COPD readmission to reduce costs. The implication is that care was incomplete or sloppy on the first admission, and that better care might reduce readmissions.

However, a number of concerns have been raised questioning the wisdom of the HRRP. Hospitals with better mortality rates for heart attacks, heart failure and pneumonia had significantly greater penalties for readmission rates (5). If this correlation is found to be true with randomized trials, then CMS is financially encouraging hospitals to perform an action with potential patient harm and suggest that CMS continues to rely on surrogate markers that have little or no correlation with patient-centered outcomes. Until this question is resolved, we cannot recommend programs that discourage hospital readmissions.

Differences between COPD Exacerbations and CHF, AMI and Pneumonia Methodology

Several aspects of COPD exacerbations differentiate it from other conditions included in HRRP. AMI, CHF, pneumonia and COPD exacerbations are all defined by discharge ICD-9 codes. Examination of ICD-9 coding against physician chart review found profound underestimation of COPD exacerbations, with sensitivities ranging from 12% to 25% and positive predictive values as low as 81.5% (6). In contrast, coding data to identify pneumonia and AMI have a sensitivity and positive predictive value of over 95% (7,8). Therefore, there is a high probability of misclassification of COPD exacerbations used to calculate the readmissions penalty.

COPD exacerbations are clinically defined while AMI and CHF are defined by biomarkers (plasma troponin, B-type natriuretic peptide) and pneumonia is defined by not only a compatible clinical situation but by consolidation on chest radiography. Because COPD symptoms overlap with many other diseases, biomarker and radiograph evidence can make accurate diagnosis difficult. Furthermore, this uncertainty in diagnosis may provide an opportunity for hospitals to game the system by excluding sicker patients who present with COPD from the readmission measure (9).

COPD may also require prolonged times for recovery as opposed to AMI, CHF, and pneumonia patients who seem to require shorter recovery times. One quarter of patients with a COPD exacerbation had not returned to preexacerbation peak expiratory flow rate by day 35 (10).

There is also a suggestion of a frequent exacerbation phenotype of COPD independent of disease severity (11). The single best predictor of exacerbations was a history of exacerbations, although a history of gastroesophageal reflux (GERD) was also associated with increased exacerbations. A hospital with higher numbers of patients with the frequent exacerbation phenotype or with GERD would be expected to have a higher readmission rate but would be penalized under CMS' HRRP.

Causes for Readmission after a COPD Exacerbation

Most patients readmitted after a COPD exacerbation are not readmitted for COPD. Shah et al. (9) recently examined nearly 200,000 COPD exacerbation hospital readmissions in the Medicare population. Only 27.6% were classified as being readmitted for COPD. There were a variety of readmission diagnosis with respiratory failure, pneumonia, CHF, asthma, septicemia, cardiac dysrhythmias, fluid and electrolyte disorders, intestinal infection, and non-specific chest pain and other accounting for the rest. This data is consistent with previous studies by Jencks et al. (12) who found 36.2% of exacerbation patients were readmitted for COPD. Not surprisingly, the sickest patients (as defined by the Charlson sum) are more likely to be readmitted (9). This would also be consistent with causes of readmission being diverse rather than limited to COPD.

Importantly, two observations were made which may have major implications for care after COPD exacerbations (9). First, patients dually enrolled in Medicare and Medicaid had higher readmission rates. These patients tend to be poorer and seek care at "safety net" hospitals. A penalty for readmissions would be largest at these hospitals which may most in need of financial help. Second, patients discharged home without home care were more likely to be readmitted. This will likely influence more discharges to either an extended care facility or with home care which may actually increase costs rather than result in the cost savings that CMS hopes to collect.

Interventions that Reduce COPD Readmissions

Jennings et al. (13) used a "bundle" for patients with COPD exacerbations in hopes of reducing readmissions and emergency department visits. The bundle consisted of smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48 hour postdischarge telephone call. It is easy to criticize these interventions. A single session of smoking cessation counseling is usually inadequate (14). Although gastroesophageal reflux disease has been associated with COPD, there is only a single trial with lansoprazole demonstrating a reduction in COPD exacerbations (15). To our knowledge there is no data on screening for depression or anxiety, standardized inhaler education and a single phone call in preventing COPD readmissions. Not surprisingly, the bundle did not work. However, it underscores that interventions to prevent COPD readmissions are unknown. Until these are defined, it seems unlikely that any program will be successful in reducing COPD readmissions.

Potential COPD Readmission Reduction Strategies

Discharge and Follow-Up

Discharge to an extended care facility or with home care reduces readmissions (9). Approximately one third of readmissions after hospitalization for COPD occur within 7 days of discharge and 60% occur within 15 days (9). Therefore, even close outpatient followup within 2 weeks of discharge from the hospital, may not prevent a majority of readmissions. However, we would recommend that close follow-up of patients be liberal which seems likely to have some impact on readmissions. Follow-up telephone calls may be reasonable but probably need to be more than a single call at 48 hours (13). We offer some additional suggestions below that have not been subjected to randomized trials, but seem reasonable based on the current state of knowledge.

Pharmacologic Therapy

1. Bronchodilators. Many of the therapies that treat COPD exacerbations have been tested to determine if chronic use might prevent exacerbations. The best evidence is for the long-acting bronchodilators. Two large randomized controlled trials have confirmed that a combination of a long-acting beta agonist (salmeterol) with an inhaled corticosteroid (fluticasone) or a long-acting anticholinergic (tiotropium) reduce exacerbations (16,17). Given that only about one-third of readmissions are due to COPD, the impact, if any, with addition of long-acting bronchodilators after a COPD exacerbation would likely be small. The newer long-acting beta agonists and anticholinergics would also be expected to reduce exacerbations and might prevent readmissions.
2. Inhaled corticosteroids. Addition of inhaled corticosteroids to long-acting bronchodilators in COPD remains controversial. A meta-analysis by Spencer et al. (18) recommended regular inhaled corticosteroid therapy as an adjunct in patients experiencing frequent exacerbations. However, the data supporting this recommendation is unclear. It is also unclear if their addition would prevent readmissions.
3. Antibiotics. Continuous or intermittent treatment with some antibiotics, particularly macrolides, reduces exacerbations. Treatment with azithromycin for one year lowered exacerbations by 27% (19). Although the mechanism(s) accounting for the reduction in exacerbations is unknown, current concepts suggest the reduction is likely secondary to the macrolides’ anti-inflammatory properties. However, concern has been raised about a very small, but significant, increase in QT prolongation and cardiovascular deaths with azithromycin (20). In addition, the recent trial with azithromycin raised the concern of hearing loss which occurred in 25% of patients treated with azithromycin compared to 20% of control (19). An alternative to the macrolides may be tetracyclines such as doxycycline, which also possess anti-inflammatory properties but do not lengthen QT intervals nor cause hearing loss (21). Similar to the long-acting bronchodilators, antibiotics might reduce readmissions, but since most readmissions are not due to COPD, the effect would likely be small.
4. Medication Compliance. Poor compliance with inhaled therapies has been implicated as a factor contributing to COPD exacerbations (22). The role of COPD medication noncompliance has not been specifically assessed in hospital readmissions, although it seems likely to be a contributing factor. Socioeconomic factors influence medication compliance and could lead to greater readmission rates in hospitals caring for patients with limited financial and social resources. Poor compliance with COPD medications as well as medications for comorbid conditions may both be important as most readmissions are not due to COPD.

Conclusions

Prevention of COPD readmissions after a COPD exacerbation represents a challenge with no straight-forward strategies to reduce readmissions other than discharge to an extended care facility or home with home health. Readmissions come from heterogeneous causes but most are not due to COPD suggesting that comprehensive care for disorders other than just COPD is likely important.

References

1. Centers for Medicare and Medicaid Services. Readmissions reduction program. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html (accessed 6/4/15).
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Reference as: Robbins RA, Wesselius LJ. Reducing readmissions after a COPD exacerbation: a brief review. Southwest J Pulm Crit Care. 2015;11(1):19-24. doi: http://dx.doi.org/10.13175/swjpcc089-15 PDF

Variation in Southwestern Hospital Charges for Pulmonary and Critical Care DRGs

Richard A. Robbins, M.D.

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

Abstract

Recently, the Centers for Medicare and Medicaid Services (CMS) released nationwide data on hospital charges and CMS payments for the top 100 disease-related groups (DRG). Data obtained from the CMS website was examined for 23 common pulmonary and critical care DRG charges and payments to hospitals in the Southwest United States (Arizona, New Mexico and Colorado). Similar to nationwide trends, charges vastly exceeded payments and varied widely. Normalizing the data to the state average for each DRG, the percent over/under the state average revealed a negative correlation between charges and payments. Urban hospitals billed more but did not receive significantly higher payments. Hospitals that were primary hospitals for residencies did not bill significantly more but did receive higher payments. These data demonstrate that charges and payments for respiratory and critical care DRGs in the Southwest mirror nationwide trends in large overcharges.

Introduction

It has commonly been accepted that hospital charges greatly exceed payments (1). Insurance companies, CMS and other groups negotiate a discounted price from the “charge master” price (1). However, in the absence of a negotiated discount, the “charge master” price applies which may result in the poor and most vulnerable paying the highest prices. In addition, it may result in overbilling for insurance companies who in some instances pay more than patients who pay cash for certain procedures (1).

Some attempt has been made to introduce transparency. For example, a bill was introduced into the Arizona legislature to require posting of hospital and physician prices (1). However, this bill died in committee. The Arizona Department of Health Services requires hospitals to report their charges which are posted on the Arizona Department of Health Services website (2). However, this information does not appear to have been disseminated widely and would appear to be seldom used by consumers when making health care decisions. Similarly, this data does not appear to be well known by healthcare providers. Recently CMS released data on hospital charges. This database was searched for common pulmonary and critical care DRG charges and payments for hospitals in the Southwest.

Methods

CMS data

Data was obtained from the CMS website (3). Hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges were examined. Also examined was the amount paid by Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011. These DRGs represent almost 7 million discharges or about 60 percent of total Medicare IPPS discharges.

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes the MS-DRG amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount.

For these DRGs, average charges and average Medicare payments are calculated at the individual hospital level. The payments are adjusted based on the wage index applicable to the area where the hospital is located, the percentage of low-income patients, if the hospital is an approved teaching hospital and for outlier cases (4).

For the purposes of comparison, urban hospitals were defined as within an urban center (Phoenix, Tucson, Denver, or Albuquerque) or within 50 miles of the city center.

Statistical Analysis

Data was reported as mean + standard error of mean (SEM). The percentage over/under for charges and payments was calculated by taking the state average for each DRG and calculating the percentage above or below for each hospital. Comparison between groups was done using the Student’s t-test. The relationship between continuous variables was obtained using the Pearson correlation coefficient. Significance was defined as p<0.05. All p values reported are nominal, with no correction for multiple comparisons.

Results

Southwest Hospital Charges by State

Covered charges are shown in Table1. Arizona and Colorado charges averaged 24% and 23% above the National average respectively while New Mexico closely approximated the National average.

Table 1. Average Southwest hospital charges for 23 common pulmonary and critical care DRGs. [Editor's Note: It may be necessary to enlarge your browser window to view this and the other tables.]

Southwest Hospital Payments by State

Payments were much lower than charges (Table 2). Payments averaged 25%, 24% and 31% of charges in Arizona, Colorado and New Mexico for the pulmonary and critical care DRGs. These closely approximated the National average of 28% for all charges.  In contrast to billings, payments averaged below the National average in the Southwest. For the pulmonary and critical care DRGs the payments were below the National average for Arizona (-3.76%), Colorado   (-7.46%), and New Mexico (-0.98%).

Table 2. Average Southwest hospital payments for 23 common pulmonary and critical care DRGs.

Individual Hospital Charges

CMS listed hospital charges from 56 hospitals in Arizona, 40 hospitals in Colorado and 31 in New Mexico. The number of DRGs from each hospital was highly variable ranging from a low of 1 to a high of 23. Hospital charges varied widely with large differences between the high and low charges (Table 3).

Table 3. Average differences between high and low charges for each pulmonary and critical care DRG. The percent is the difference between the high and low compared to the state average.

Charges by individual hospitals as a percentage of the average for each state are listed in Appendix 1.

Urban hospital billings were higher than rural hospital billings (3.0 + 3.0% vs. -14.5 + 4.4% of the state average, p= 0.001).

Hospitals charges for the 9 hospitals that are primary hospitals for residencies in the Southwest (6 in Arizona, 2 in Colorado and 1 in New Mexico) averaged 4.0% over the average for their respective state (p=0.21 compared to the other hospitals). In contrast, these hospitals received payments that were 28.9% over their state average (p= 0.015 compared to the other hospitals).

Individual Hospital Payments

CMS listed hospital payments from 56 hospitals in Arizona, 40 hospitals in Colorado and 31 in New Mexico. Like the hospital charges, the number of DRGs from each hospital was highly variable ranging from a low of 1 to a high of 23. Hospital payments varied but less between high and low payments than charges (Table 4).

Table 4. Average differences between high and low payments for each pulmonary and critical care DRG. The percent is the difference between the high and low compared to the state average.

Payments to individual hospitals as a percentage of the average for each state are listed in Appendix 2.

For the Southwestern states there was an inverse relationship between percent of the state average of charges and percent payments (r = -0.2243, p = 0.0112). In other words, the higher the percent charges compared to the state average, the lower the percent payments compared to the state average.

Urban hospital payments did not significantly differ from rural hospital payments (0.8 + 2.7% vs. 7.8 + 3.3% of the state average, p= 0.103).

Hospitals payments to the 9 hospitals that are primary hospitals for residencies in the Southwest averaged 28.9% over their state average (p= 0.015 compared to the other hospitals).

Discussion

The data in this manuscript demonstrates that hospital charges to CMS in the Southwest US for common pulmonary and critical care DRGs greatly exceed CMS payments. These charges reflect national trends for other DRGs (1-5). The data also suggest that there is wide variability in charges between hospitals, again reflecting national trends. Payments also vary, but the degree of variability is much less. Interestingly, higher charges to CMS were associated with lower CMS reimbursement.

The data showing the range of hospital bills does not explain why one hospital charges significantly more for the same DRG than another hospital. Some hospitals have said that higher bills they sent to CMS reflected the fact that they were either teaching hospitals or they had treated sicker patients (5). CMS does make higher payments to certain hospitals based on the wage index applicable to the area where the hospital is located, the percentage of low-income patients, if the hospital is an approved teaching hospital and for outlier cases. However, the inverse relationship we found between the charges and payments in the Southwest US for pulmonary and critical care DRGs suggest that the higher billings are not based on the CMS adjustments.

Teaching would not appear to explain the differences in hospital billing. There are 9 hospitals that are known primary hospitals for residencies in the Southwest (6 in Arizona, 2 in Colorado and 1 in New Mexico). These hospitals had billings that averaged only 4.0% over the average for their respective state. In contrast, these hospitals received payments that were 28.9% over their state averages.

Similarly, high labor costs likely do not explain the differences in billing. The urban centers where wages tend to be higher did bill higher but their payments did not differ. This would seem to indicate that higher billings are not based on higher labor costs. There was considerable variability in billing. For example, the medical centers with the highest billing in each state were in Bullhead City, Arizona (Western Arizona Regional Medical Center); Littleton, Colorado, a suburb of Denver (Centura Health-Littleton Adventist Hospital) and Roswell, New Mexico (Eastern New Mexico Medical Center).

There are several limitations to our study. Hospital billings and payments are based on CMS data. In several instances the average data is based on only one or two DRGs. Billing and payments vary considerably from state to state and it is unclear if this data from the Southwest reflects national trends.

The hospital industry is quick to point out that the charges are irrelevant because private insurers, Medicare or even the uninsured do not pay these amounts (5). Medicare sets standard rates for treatments and insurers negotiate with hospitals. However, experts add that the charges reflect decades of maneuvering by hospitals to gain an edge over insurers and provide themselves with tax advantages. A hospital could use the higher prices when calculating the amount of charity care it was providing. Charity care is important to hospitals which need to demonstrate provision of a high level of “community benefit” in order to maintain its status as a nonprofit hospital. However, the IRS has recently issued new rules that require a hospital to charge uninsured patients a rate that is not more than the “amounts generally billed” to patients with insurance coverage (6).

A small number of hospitals have adopted a strategy to increase their profits by “going out of network” (5). The hospitals sever ties and hence contractual agreements that limit reimbursement rates, with large private insurers. An out-of-network hospital can bill a patient’s insurer at essentially whatever rate it cares to set which likely reflect the “charge master” price. While the insurers can negotiate with the hospital, they generally end up paying more than they would have under a contractual agreement. Data regarding the network affiliations of the hospitals in the Southwest is unavailable.

Transparency in healthcare pricing is needed but few hospitals or physicians have adopted this as a standard policy. One that does post prices is the physician-owned Surgery Center of Oklahoma (7). Their prices appear to be about 50 to 75 percent lower than most major hospitals. Whether this business model will grow as an approach to attract patients is unclear.

Physicians need to act as patient advocates including advocating for affordable healthcare. Transparency is one part in achieving this goal. The release by CMS of hospital charges and payments is a step towards transparency. Release of similar data by healthcare providers and insurers will enhance the transparency and will likely lead to more affordable healthcare for the majority of patients.

References

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7. http://www.surgerycenterok.com/index.php (accessed 5/27/13).

Reference as: Robbins RA. Variation in southwestern hospital charges for pulmonary and critical care DRGs. Southwestern J Pulm Crit Care. 2013;7 (1):31-7. doi. http://dx.doi.org/10.13175/swjpcc074-13 PDF