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A roadmap for comparing readmission policies with application to Denmark, England and the United States

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A roadmap for comparing readmission policies with application to Denmark, England and the United States
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  Pleasecitethisarticleinpressas:KristensenSR,etal.AroadmapforcomparingreadmissionpolicieswithapplicationtoDenmark,EnglandandtheUnitedStates.HealthPolicy(2014),http://dx.doi.org/10.1016/j.healthpol.2014.12.009 ARTICLE IN PRESS G Model HEAP-3340;No.ofPages10HealthPolicyxxx(2014)xxx–xxx ContentslistsavailableatScienceDirect Health   Policy  journalhomepage:www.elsevier.com/locate/healthpol A   roadmap   for   comparing   readmission   policies   withapplication   to   Denmark,   England   and   the   United   States Søren   Rud   Kristensen a , b ,   Mickael   Bech b , ∗ ,   Wilm   Quentin c , d a ManchesterCentreforHealthEconomics,UniversityofManchester,UK  b COHERE–CentreofHealthEconomicsResearch,DepartmentofBusinessandEconomics,UniversityofSouthernDenmark,Denmark c DepartmentofHealthCareManagement,BerlinUniversityofTechnology,Germany d EuropeanObservatoryonHealthSystemsandPolicies,Brussels,Belgium a   r   t   i   c   l   e   i   n   f   o  Articlehistory: Received7August2014Receivedinrevisedform4December2014Accepted8December2014 Keywords: HospitalreimbursementReadmissionratesProviderpaymentReadmissionpoliciesAvoidablereadmissions a   b   s   t   r   a   c   t Hospital   readmissions   receive   increasing   interest   from   policy   makers   because   reducingunnecessary   readmissions   hasthe   potential   to   simultaneously   improve   quality   and   savecosts.   This   paper   reviews   readmission   policies   in   Denmark,   England,   Germany   and   theUnited   States   (Medicare   system).   The   suggested   roadmap   enables   researchers   and   policymakers   to   systematically   compare   and   analyse   readmission   policies.   We   find   considerabledifferences   across   countries.   InGermany,   the   readmission   policy   aims   to   avoid   unintendedconsequences   of    the   introduction   of    DRG-based   payment;   it   focuses   on   readmissions   of individual   patients   and   hospitals   receive   only   one   DRG-based   payment   for   both   the   initialand   the   re-admission.   In   Denmark,   England   and   the   US   readmission   policies   aim   at   qualityimprovement   and   focus   onreadmission   rates.   InDenmark,   readmission   rates   are   publiclyreported   but   payments   are   not   adjusted   in   relation   toreadmissions.   In   England   and   the   US,financial   incentives   penalise   hospitals   with   readmission   rates   above   a   certain   benchmark.InEngland,   this   benchmark   is   defined   through   local   clinical   review,   while   it   isbased   onthe   risk-adjusted   national   average   in   the   US.Atpresent,   not   enough   evidence   exists   to   giverecommendations   onthe   optimal   design   of    readmission   policies.   The   roadmap   can   be   atoolfor   systematically   assessing   how   elements   of    other   countries’   readmission   policies   canpotentially   be   adopted   to   improve   national   policies.©2014   Published   byElsevier   Ireland   Ltd.   This   is   an   open   access   article   under   the   CCBY-NC-ND   license   (http://creativecommons.org/licenses/by-nc-nd/3.0/). 1.Introduction Healthcaresystemsaroundtheworldareunderpressuretodelivervalueformoney[1,2]withpoli-cymakerssimultaneouslyaimingtocontrolcostsandimprovethequalityofcare.Reducingunnecessaryhospi-talreadmissionsseemstobeanattractivemeanstothatend,asfewerreadmissionscanpotentiallybothreducecostsandimprovethequalityofcare[3,4].InEngland, ∗ Correspondingauthor.Tel.:+4565504234. E-mailaddress: mbe@sam.sdu.dk(M.   Bech). in2011–2012the28daysemergencyreadmissionratewas11.5%–anincreasefrom9%in2002–2003[5].Inthe UnitedStates(US),16%ofMedicarebeneficiarieswho   weredischargedfromhospitalhadanunplannedreadmissionwithin30daysin2011[6].Hospitalreadmissionshavebeenofinteresttoresearchersandpolicymakerssincethelate1970s[7].However,itisonlyrelativelyrecentlythatpoliciesweredevelopedinseveralcountrieswiththespecificaimof reducingreadmissions.Interestinthelinkbetweenfinan-cialincentivesandreadmissionsincreasedconsiderablyintheearly1980s,whenDRG-basedhospitalpaymentwasintroducedintheUnitedStates[8].UnderDRG-based http://dx.doi.org/10.1016/j.healthpol.2014.12.0090168-8510/©2014PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/3.0/).  Pleasecitethisarticleinpressas:KristensenSR,etal.AroadmapforcomparingreadmissionpolicieswithapplicationtoDenmark,EnglandandtheUnitedStates.HealthPolicy(2014),http://dx.doi.org/10.1016/j.healthpol.2014.12.009 ARTICLE IN PRESS G Model HEAP-3340;No.ofPages102   S.R.Kristensenetal./HealthPolicyxxx(2014)xxx–xxx payment,hospitalsarepaidafixedamountperadmission,withtheamountdependingoncertainpatientandtreat-mentcharacteristics[9].Consequently,incentiveswere introducedforhospitalstoincreasetheirincomebyadmit-tingmorepatients,andpossiblytoreadmitpatientsasnewadmissionsforfinancialreasons[10].Therefore,atthetime, itwasspeculatedthatsomereadmissionsmightbe“avoid-able”underadifferentsetofincentives[11–13].Following theintroductionofDRG-basedhospitalpaymentsystemsinmostEuropeancountries[14],similarconcernsemerged (forexampleinGermany[15],England[16],andFrance [17]).RecentpolicyattemptstoreducereadmissionratesinEnglandandtheUnitedStates(US)haveincommonarelianceonfinancialpenalties.ItisperhapslesswellknownthatGermanyintroducedsimilarfinancialincentivesforhospitalstoavoidreadmissionsmorethan10yearsago.Incomparison,inDenmark,readmissionratesaremoni-toredbutthereisnonationalpolicyconcerningtheuseof financialincentives.Theuseoffinancialpenaltiestoreducereadmissionrateshasbeenmet   withsomeresistancefromthemedicalcommunitiesinEnglandandtheUS[18,19].IntheUS,the importanceofriskadjustment,andwhichfactorstoincludeinsuchadjustmenthasattractedparticularattention,andithasbeenhighlightedthatforexamplecommunitychar-acteristicsarelikelytobeimportantfactorsinfluencingreadmissionrates[19–22].Thedebatehasalsofocusedattentiononthefactthatthespecificincentivesofdifferentpoliciesaredecisiveindeterminingwhetherapolicyissuccessful[3,23].Recog- nisingtheimportanceofdifferentpolicydesigns,areviewofcurrentnationalpolicyapproachestodealingwithread-missionshasthepotentialtoprovidevaluablelearningandinspirationforfuturereformacrosscountriescurrentlystrugglingwithsimilarproblems.Currently,asystematiccomparisonofreadmissionpoli-ciesacrossdifferentcountriesisunavailable.Thispaperaimstofillthisgapbyprovidingandapplyingaroadmapforsystematicallycomparingreadmissionpoliciesacrossfourhigh-incomecountrieswithdifferentinstitutionalsettings:Denmark,England,GermanyandtheUnitedStates(Medi-careinpatientprospectivepaymentsystem,IPPS).Thesecountriesrepresentillustrativedifferencesindealingwithreadmissionsandareinformativecasesfordemonstrat-ingtheuseofourroadmap.We   beginbydevelopingaroadmapofpoliciesdistinguishingbetweenpoliciesforthemeasurementandmanagementofhospitalreadmissions.Subsequently,weapplytheroadmaptoreadmissionpoli-ciesintheselectedcountries,andlessonsarisingfromthecomparisonarediscussed. 2.Methods:aroadmapforanalyzingreadmissionpolicies We   gatheredinformationandreviewedofficialdocu-mentsandpolicystatementsforrelevantcountry-specificlawsandregulationsforthecountriesincludedinthestudy.Thelawsandregulationscouldbeeitherspecificreadmissionpoliciesorpoliciesthatindirectlyinfluencehospitals’incentivestoreducereadmissions.Thepolicies[24–27]wereanalysedinordertoidentifysimilaritiesanddifferencesacrosscountries,andtoidentifycharacteristicfeaturesofdifferentpolicies.Analysisoftheidentifiedpoliciesledtotheidentifica-tionoftwomaindimensionsofreadmissionpolicies:(1)readmissionmeasurementand(2)readmissionmanage-ment(seeFig.1).Policiescanfocuseitheronreadmission ofindividualpatientsoronreadmissionrates.Theaimof thepolicyandtheintendedaudiencedeterminethespe-cificcharacteristicsofhowreadmissionsaremeasuredandhowthisinformationisusedforreadmissionmanagement.  2.1.Readmissionmeasurement  2.1.1.Focusofreadmissionpolicies:individualpatientsorreadmissionrates Readmissionpoliciescanfocusonmeasuringandman-agingreadmissionsofindividualpatientsortheycanfocusonreadmissionrates.Ifthefocusisonreadmissionrates,adenominatorandnumeratormustbedefined,andthelevelatwhichratesarecalculatedmustbechosen[28].Depend- ingontheaimandaudience,thislevelcouldbethenation,theregion,thehospitalorthehospitaldepartment.Apolicyfocussingonthereadmissionofindividualpatientshastheadvantagethatitdirectstheattentiontothequestionofhowtoavoidaspecificreadmissionofanindividualpatientoraspecificgroupofpatients.Afocusonreadmissionrateshastheadvantagethatitenablesbench-markingofreadmissionratesacrossthechosenaggregateunits.  2.1.2.Definitionofrelevantreadmissions Independentofwhetherthefocusisonindividualreadmissionsoraggregatereadmissionrates,readmissionmeasurementalwaysrequiresacleardefinitionofwhatarelevantreadmissionis:ingenericterms,areadmissionisasecondadmissiontoahospitalwithinaspecifiedperiodof timeafteraprimaryorindexadmission.Thereadmissionisdefinedbycriteriafortheinitialadmission,criteriaforthesubsequentsecondadmission,andtherelevanttimeperiodbetweenthetwo   admissions[29–31].Bothadmissionscan bespecifiedintermsofinclusionorexclusioncriteria.Arelevantindex-andsecondadmissioncanbedefinedintermsofthepatients’clinicalcharacteristics(e.g.thediagnosis),demographiccharacteristics(e.g.ageandgen-der),thespecialtywherepatientsweretreated,ortheadmissiontype(e.g.emergencyorelectiveadmission).Thesespecificationscanbethesameordifferentfortheindexandthesecondadmission.Forexample,thedef-initionofrelevantreadmissionscouldspecifythatonlyemergencyadmissionsfollowinganinitialelectiveadmis-sionaretobeincluded.Ifreadmissionratesarecalculated,theindexadmissiondefinesthedenominatorpopulation,whilethenumberofsecondadmissionswithintherelevanttimeperioddefinesthenumerator.Thetimeperiodhastobespecifiedinordertodeterminewhetherasecondadmissionistobeconsideredarelevantreadmissionandnotjustanotherprimaryadmission.Timecanbemeasuredfromdischargeoftheindexadmission,orfromthefirstdayoftheinitialadmission.Thechoiceof criteriafortheindexadmission,thesecondadmission,and  Pleasecitethisarticleinpressas:KristensenSR,etal.AroadmapforcomparingreadmissionpolicieswithapplicationtoDenmark,EnglandandtheUnitedStates.HealthPolicy(2014),http://dx.doi.org/10.1016/j.healthpol.2014.12.009 ARTICLE IN PRESS G Model HEAP-3340;No.ofPages10 S.R.Kristensenetal./HealthPolicyxxx(2014)xxx–xxx 3 Fig.1. Aroadmapforhealthsystempoliciesforhospitalreadmissions. thetimeframedependontheaudienceoftheindicatorandthepurposeofmeasuringreadmissions.  2.2.Systemlevelreadmissionmanagement  Ingeneral,theaimofmeasuringthenumberortherateofreadmissionsistogeneratethenecessarybackgroundinformationformanagingreadmissions[29].Systemlevel readmissionmanagementinvolvestheprovisionofsystemlevelincentivestoreducereadmissions.Itistheintentionofsuchpoliciesthattheywillgenerateincentivesforreduc-ingreadmissionsatalocallevel.Thiscanbeintheformof changestoin-patientcaresuchasintroducingcaseman-agersandimprovingdischargeinformation,orintheformoffollow-upcommunitycare.Anon-financialincentiveisthepublicationorpublicreportingofreadmissionrates,e.g.showinganindivid-ualhospital’sperformancerelativetootherhospitals.Thiscan,intheory,reducereadmissionsthroughtwointer-connectedpathways,aselectionpathway,wherepatientsselecthospitalswithlowerreadmissions(demandreac-tion),andachangepathway,wherehospitalsreducereadmissionsbecausetheyfindthemselvesunderperform-ing[32–34].Financialincentivesmay   includebonusesfor“good”performance,i.e.forreducingthenumberortherateof readmissions,or“penalties”forhospitalswithhighernum-bersorratesofreadmissions.Penaltiescanbeintheformofnon-reimbursementforanindividualreadmission,areductionofreimbursementorevenintheextremecasenoreimbursementandapenaltyforthehospital.Inthecasewherefinancialincentivesarelinkedtoreadmissionratesandnottoindividualreadmissions,aperformancebenchmarkhastobeestablishedagainstwhichthehospitalspecificratecanbecompared.Theperformancebenchmarkcanbeabsoluteorrela-tivetotheindividualprovider’sperformanceinapreviousperiod(alocalbenchmark)orotherproviders’performance(aglobalbenchmark).Forexample,anabsolutebench-markcanbesetonthebasisofexpertopinion.Arelativebenchmarkmightbedefinedasperformancebelowacer-tainquantileofthedistribution.Inaddition,readmissionratesareusuallyrisk-adjustedwhentheyarecomparedwiththebenchmarkbecauserateshavebeenfoundtovarywitharangeoffactorssuchasage,gender,co-morbiditiesandtreatmentsetting(inpatientoroutpatientcare)[29,35–37]. 3.Results:readmissionpoliciesinDenmark,England,Germany,andtheUnitedStates  3.1.Introduction,audienceandaimsofreadmission polices Table1showsthatreadmissionpolicieswereintroducedrelativelyrecentlyinallfourcountries.Englandwasthefirstcountrytointroducemeasurementofreadmissionratesandtomakethisinformationpubliclyavailablein2001.Denmarkstartedmeasuringreadmis-sionsin2002butintroducedpublicreporting(initiallyfor35typesofsurgery)onlyin2006.IntheUS,publicreportingwasintroducedforhospitalspaidundertheIPPSin2010.InGermany,thecurrentreadmissionpolicy,whichincludestheprovisionoffinancialincentives,was   introducedin2004togetherwiththenationwideintroductionoftheDRG-basedhospitalpaymentsystem(Table1).Inallcountries,informationonreadmissionsiscollectedtoinformthepayersandprovidersinthenationalhospitalcaresystem.Inaddition,allcountriesexceptforGermanymakeinformationonreadmissionsavailabletothepub-lic.Thestatedaimofmeasuringreadmissionsvariesfrom  Pleasecitethisarticleinpressas:KristensenSR,etal.AroadmapforcomparingreadmissionpolicieswithapplicationtoDenmark,EnglandandtheUnitedStates.HealthPolicy(2014),http://dx.doi.org/10.1016/j.healthpol.2014.12.009 ARTICLE IN PRESS G Model HEAP-3340;No.ofPages104   S.R.Kristensenetal./HealthPolicyxxx(2014)xxx–xxx  Table1 Introduction,audiencesandaimsofreadmissionpoliciesinDenmark,England,Germany,andtheUnitedStates.CountryIntroductionAudienceAimDenmarkAdministrativemeasurement:2002Publicreporting:2006Hospitals,regions,municipalities,thepublicToincreaseawarenessof variationinreadmissionratesatalllevelsofthehealthcaresystem,supportpatients’freechoiceofhospitalandforpublicreportingEnglandPublicreporting:2001Financialincentives:Apr-2011TheNHSandthepublicPublicreporting:tomonitorsuccessinavoiding(orreducingtoaminimum)readmissionfollowingdischargefromhospital”[51]Financialincentive:toreducetheactuallevelofemergencyreadmissionintohospitalbymakinghospitalsresponsibleforpatientsforthe30daysafterdischargeGermany2004(withthecountry-wideintroductionofDRG-basedhospitalpayment)TheInstitutefortheHospitalReimbursementSystem(InEK)actingonbehalfoftheAssociationofSicknessFunds(GKV),theAssociationof PrivateHealthInsurers(PKV)andtheGermanHospitalFederation(DKG)Avoidingunintendedconsequences,i.e.increasedreadmissions,resultingfromtheintroductionoftheDRG-basedhospitalpaymentsystem[15]USA(Medicare) Publicreporting:2010Financialincentives:Oct-2012Hospitals,policymakers,andotherstakeholdersPublicreporting:toimprovehealthcarequality,populationhealth,toreducethecostsof healthcare,andtoallowhospitals,policymakers,andotherstakeholderstoevaluatethequalityofcareandtoseekimprovementsthatwillimpactpatientwell-beingFinancialincentives:totransformMedicarefromapassivepayertoonethatpaysnotjustforquantityofservicesbutforqualityaswell aimingtoincreasetheawarenessofvariationinreadmis-sionrates(Denmark),toanaimofusingthisawarenesstoreduceavoidablereadmissions(England,Germany,US),whichinthecaseofGermanyisrecognisedasbeingapotentialunintendedconsequenceembeddedinaDRG-basedpaymentsystem,andinthecaseoftheUSexplicitlyseenasawayofreducingcostsandincreasingquality.  3.2.Readmissionmeasurement  3.2.1.Focusofreadmissionpolicies:thelevelatwhichreadmissionsaremeasured Table2showsthatreadmissionpoliciesfocusonmea-surementofreadmissionsatdifferentlevels.Denmark,England,andtheUSmeasurereadmissionsratesatthehospitallevel.DenmarkandEnglandalsocalculateread-missionratesatvariousregionallevels.Inaddition,allthreecountriescalculatecondition-specificreadmissionratesforalimitednumberofconditions,aswellasall-causeread-missionrates.InGermany,bycontrast,thereadmissionpolicyfocusesontheindividualpatient.Arelevantreadmissionisidentifiedbythehospital(orthepayer),whenanindivid-ualpatientisreadmittedtothehospital.Subsequently,thehospitalhastomergethepatient’srecordsfromthetwoadmissionsintoasinglefile,andthisbecomesrelevantforreimbursement(seeSection3.3.1).  3.2.2.Definitionofrelevantreadmissions Table2alsoshowsthatDenmark,England,andGermanyconsiderreadmissionsforalmostallconditionstoberelevant.InGermany,certainrestrictionsapplyinsofarasonlyreadmissionsforthesamereasonsorforcom-plicationsoftreatmentareconsideredtoberelevant.Bycontrast,intheUS,onlyreadmissionsforacutemyocar-dialinfarction(AMI),heartfailure(HF)andpneumonia(PN)arecoveredunderthecurrentreadmissionpolicy,althoughinclusionofthreemoreconditions(chronicobstructivepulmonarydisease,totalhiparthroplastyandtotalkneearthroplasty)isplannedfor2015.InDenmark,EnglandandtheUS,thedefinitionof relevantreadmissionsexcludesplannedreadmissions.InEngland,onlyemergencyreadmissionsareconsideredtoberelevantreadmissions.Therationaleforexcluding  Pleasecitethisarticleinpressas:KristensenSR,etal.AroadmapforcomparingreadmissionpolicieswithapplicationtoDenmark,EnglandandtheUnitedStates.HealthPolicy(2014),http://dx.doi.org/10.1016/j.healthpol.2014.12.009 ARTICLE IN PRESS G Model HEAP-3340;No.ofPages10 S.R.Kristensenetal./HealthPolicyxxx(2014)xxx–xxx 5  Table   2 ReadmissionmeasurementinDenmark,England,Germany,andtheUnitedStates.CountryLevelatwhichreadmissionsaremeasuredDefinitionofrelevantreadmissionsDefiningcriteriaExceptionsTimeframeof measurementDenmarkHospital,municipality,diseaseAllsecondacuteadmissionsinpublicandprivatehospitalsThegeneralindicatorshavenoexemptions,butexemptionsapplytowithindiseasespecificindicators30daysfromdischargeEnglandForpublicationpurposes:StrategicHealthAuthorities,NHSTrusts,MentalHealthTrusts,GovernmentOfficeRegions,PrimaryCareOrganisations,LocalAuthorities,HospitalTrusts,Country,County,IndependentSectorHealthCareProviders,PrimaryCareTrusts,Regions,GenderandconditionForreimbursementpurposes:HospitalTrustlevelForpublicationpurposes:Allcausereadmissionrateandspecificratesfor:fracturedproximalfemur,hipreplacement,hysterectomy,strokeForreimbursementpurposes:Emergencyadmissionsafteranemergencyorelectiveindexadmission.Forpublicationpurposes:–patients<16yearsofageForreimbursementpurposes:–HRGsthatdonothaveanationaltariff –Maternityandchildbirth–Cancer,chemotherapyandradiotherapypatients–Childrenunderage4–Patientswhodischargedthemselvesagainstclinicaladvice–Emergencytransfersfromanotherprovider–   Cross-borderactivity–   Patientsreceivingrenaldialysis–TransplantpatientsForpublicationpurposes:28daysfromdischargeForreimbursementpurposes:30daysfromdischargeGermanyIndividualpatient(1)Asecondadmissionsforthesamereason(withinthesamebase-DRG)(2)Asecondadmissionforthesamereason(withinsameMDC)ifthepatientwasfirstamedicalcaseandisnowtreatedwithsignificantprocedures(e.g.surgery)(3)AsecondadmissionforcomplicationsoftreatmentExceptionsaredefinedattheDRGlevel.ExemptedDRGsareindicatedintheDRGcatalogue:–maternalandnewborncare–   DRGswithICUtreatment–certaincancercases(haematologicalcancer,radiotherapy)–paintherapy–renaldialysis–   allpre-MDCDRGs(includingtransplants)–errorDRGs(surgeryunrelatedtothemaindiagnosis) → about23%ofallDRGsareexemptedfromthepolicyFor(1)and(3)therelevanttimeperiodistheupperlengthofstaythresholdof therelevantDRG(countedfromthedayofinitialadmission).ThethresholddependsonthespecificDRG.E.g.itis4daysfortheDRGforcertainophthalmologicalsurgeriesand70daysfortheDRGforcraniotomywithradiotherapy.For(2)within30daysfrominitialadmissionUSA   (Medicare)Forpublicreporting:Hospital-WideAll-causeandseparatelyforAMI,COPD,Hip/knee,HF,PN,StrokeForfinancialincentives:Hospitalbycondition(AMI,HF,PN).FromFY2015alsoCOPD;electivetotalhiparthroplasty(THA)andtotalkneearthroplasty(TKA)AsecondadmissionafterdischargefromadmissionforAcuteMyocardialInfarction(AMI)HeartFailure(HF)orPneumonia(PN)Plannedreadmissions(obstetricaldelivery,transplantsurgery,maintenancechemotherapy,rehabilitationandnon-acutereadmissionforascheduledprocedure)30daysfromdischarge plannedreadmissionsisthatthesedonotconstitutepoorqualityofcare.InGermany,plannedreadmissionsarealsocoveredbythepolicy.Theobjectiveistoavoidthathos-pitalscanartificiallyincreasetheirrevenuebysplittingonehospitalstayintotwoadmissions.Forexample,intheabsenceofthereadmissionpolicy,itwouldbepossibleforhospitalstobilltwoDRGsiftheydischargeapatientafteradiagnosticprocedureandsubsequentlyreadmitthepatientafewdayslaterforsurgery.England,Germany,andtheUSexemptcertaincondi-tionsfromthereadmissionpolicy.Theexemptionsalwaysincludetransplants,maternalandnewborncare,cancers
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