Prospective payment system

About: Prospective payment system is a research topic. Over the lifetime, 1958 publications have been published within this topic receiving 36437 citations.

Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure

Abstract: IN THE UNITED STATES, HALF OF INpatients older than 65 years with congestive heart failure (CHF) are readmitted within 6 months of hospital discharge, with payments totaling 60% of Medicare reimbursements for CHF, the leading diagnosis related group (DRG) for acute hospitalization and readmission in this population. Readmissions have increased since the introduction of the Medicare Prospective Payment System and may reflect suboptimal assessment of readiness for discharge, fragmented discharge planning, a breakdown in communication and information transfer between hospital-based and community physicians, inadequate postdischarge care and follow-up, or some combination of these processes, whose resolution may require better coordination of care or comprehensive discharge planning. Comprehensive discharge planning plus postdischarge support may reduce readmission rates and improve health outcomes for patients with CHF. Previous reviews of CHF disease management have emphasized beneficial effects of outpatient care and multidisciplinary teams; however, the efficacy of programs incorporating discharge planning, transitional care, and postdischarge management for this patient population has not been established. We sought to extend the results Author Affiliations are listed at the end of this article. Corresponding Author: Christopher O. Phillips, MD, MPH, Brigham and Women’s Hospital, 75 Francis St, Tower 5-509A, Boston, MA 02115 (chr_phi @yahoo.com). Context Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).

Hospital Readmissions Reduction Program

Abstract: Hospital readmission measures have been touted not only as a quality measure but also as a means to bend the healthcare cost curve. The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012. Under this program, hospitals are financially penalized if they have higher-than-expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia. The HRRP has garnered significant attention from the medical community, both positive and negative. Here, we describe the reasons the HRRP was implemented, the penalties levied, the impact it has had on transitional care and readmissions, the pros and cons of the policy, and its future. Hospital readmissions are associated with unfavorable patient outcomes and high financial costs.1,2 Causes of readmissions are multifactorial, and rates vary substantially by institution.3,4 Historically, nearly 20% of all Medicare discharges had a readmission within 30 days.1 The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable. Preventing even 10% of these readmissions could save Medicare $1 billion.5 Therefore, reducing hospital readmissions has been made a national priority. In 2008, the Medicare Payment Advisory Commission recommended to Congress that the Centers for Medicare & Medicaid Services (CMS) begin confidentially reporting readmission rates and resource use to hospitals and physicians.6 In 2009, CMS began publicly reporting hospital-level readmission rates, which were added to the Hospital Compare Web site.7 Before 2012, hospitals had little direct financial incentive to reduce readmissions. For Medicare beneficiaries with inpatient stays, hospitals receive payment with the inpatient prospective payment system (IPPS). This payment, based on a diagnosis-related group (DRG), covers the inpatient stay and any outpatient diagnostic and admission-related outpatient nondiagnostic services provided by the institution on the date of the patient’s admission or within 3 days immediately …

Accuracy of Diagnostic Coding for Medicare Patients under the Prospective-Payment System

Abstract: Reimbursement of hospitals by Medicare under the prospective-payment system is based on patients' diagnoses as coded at discharge. During the period October 1984 through March 1985, we studied the accuracy of the coding for diagnosis-related groups (DRGs) in hospitals receiving Medicare reimbursement. We used a two-stage cluster method to sample 7050 medical records from 239 hospitals that were stratified according to size. Using blinded techniques with reliability checks, medical-record specialists reabstracted the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to assign correct DRGs to discharged patients. The correct DRGs were then compared with those originally assigned by the physician and the hospital administration. The study revealed an error rate of 20.8 percent in DRG coding. Errors were distributed equally between physicians and hospitals. Small hospitals had significantly higher error rates. Previous studies had found that errors occurred randomly, so that half the errors benefited the hospital financially and half penalized the hospital. The present study found that a statistically significant 61.7 percent of coding errors favored the hospital. These errors caused the average hospital's case-mix index--a measure of the complexity of illness of the hospital's patients--to increase by 1.9 percent. As a result, hospitals received higher net reimbursement from Medicare than was supportable by the medical records. We conclude that "creep" does occur in the coding of DRGs, resulting in overpayment to hospitals for patients covered by Medicare.

Hospital characteristics and quality of care.

Abstract: Objective. —To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. Design. —Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. Setting. —Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. Patients. —A total of 14008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. Outcome Measures. —Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. Results. —Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists overtime, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. Conclusions. —The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care. ( JAMA . 1992;268:1709-1714)