Association Between Medicare Policy Reforms and Changes in Hospitalized Medicare Beneficiaries' Severity of Illness

Abstract

Key Points Question Did the expansion of secondary diagnosis codes in January 2011 allow more diagnosis codes to be reported per hospitalization, and were incentive payments for health information technology associated with changes in measured severity of illness? Findings In this cohort study of 47 951 443 discharges at 2850 hospitals, expansion of secondary diagnosis coding positions was associated with a statistically significant increase in measured severity of illness among hospitalizations for all diagnoses, diagnoses commonly targeted by incentive programs, and untargeted diagnoses. Health information technology incentives were associated with a statistically significant increase in condition categories for all diagnoses and targeted diagnoses. Meaning Changes in Medicare policies appear to be associated with increases in measured severity of illness; related policy changes may incentivize more thorough documentation of disease burden without underlying changes in patient severity.

Changes in coding of pneumonia and impact on the Hospital Readmission Reduction Program

“…Fifth, we did not make explicit allowance for changes in the intensity of comorbidity coding practices over time. As shown in Table —and documented in two recent studies—the reporting of comorbidities in conjunction with HRRP‐eligible diagnoses increased over the period of our study. This trend is likely related to the introduction of a new standard for the electronic submission of hospital claims between 2010 and 2012 …”

“…One such concern relates to hospital coding practices. Changes in coded severity or diagnosis definitions have the potential to improve hospitals' measured performance under the HRRP without reflecting improved quality . Readmission rates for patients with pneumonia may have been particularly vulnerable to variations in provider coding practices since many pneumonia inpatients may reasonably be assigned principal diagnoses other than pneumonia .…”

“…hospitals' measured performance under the HRRP without reflecting improved quality. 9,10 Readmission rates for patients with pneumonia may have been particularly vulnerable to variations in provider coding practices since many pneumonia inpatients may reasonably be assigned principal diagnoses other than pneumonia. 11,12 Shifting high-risk patients to principal diagnoses of aspiration pneumonia and sepsis-diagnoses not included the HRRP's definition of pneumonia until a rule change in fiscal year 2015-could have improved hospitals' measured readmission performance under the HRRP.…”

Association Between Financial Incentives in Medicare's Hospital Readmissions Reduction Program and Hospital Readmission Performance

“…Earlier research showing reductions in national readmissions after HRRP implementation 13,21 has been called into question by evidence that nonperformance factors are associated with inflated observed reductions in risk-standardized readmission ratios over time. [22][23][24] Other researchers have reported that upcoding is responsible for a large proportion of observed improvement in performance under HRRP, 24 but in our study, such bias might be toward the null given that hospitals with smaller baseline incentives may be more likely to upcode (with the assumption that better-resourced hospitals perform better and have the administrative capacity to code claims most efficiently).…”

Sex Differences in Care Need and Survival in Patients Admitted to Nursing Home Poststroke

“…34 While financial incentives may motivate the overestimation of care needs, we do not think that any potential misclassification of care needs would differentially affect men or women. 35 Finally, we were only able to examine baseline differences after admission to nursing home and did not have data on subsequent treatment or interventions once admitted. We also acknowledge that there are other important care needs in nursing home, such as pressure ulcers or malnutrition, that we have not included in the current study.…”