Analytic value
- The CMS readmission methodology links each readmission event back to the original (index) admission, allowing users to analyze the readmission event conditions by type of admission, date, and specific providers. This new methodology helps to identify the principal contributors and trends in readmission.
- Readmission logic applies a hierarchical clinical classification system to the original admission. This allows users to answer questions such as: Are readmission events isolated to surgical admission? Neurology? Other? If yes, which procedures or diagnoses contribute to this trend? This process allows users to identify and address these trends, and can help improve care while managing the risks and costs of readmission.
About the methodology
Developed by Yale New Haven Health Services Corporation/ Center for Outcomes Research and Evaluation (YNHHSC/ CORE), CMS readmission logic provides hospital-wide, all-condition readmission metrics that can help measure and assess the overall quality of care at a given inpatient facility.
CMS readmission methodology classifies all eligible admissions and sources of readmission into five clinical cohorts: surgical/gynecological, medical, cardiovascular, cardiorespiratory and neurology.
Excluded from CMS readmission logic are admission and readmission events for patients who leave against medical advice and admissions for conditions that are not traditionally addressed in short-stay, acute-care hospitals. The measure also excludes possible planned readmissions, as these events are not correlated with poor quality of care.
In their public reporting, CMS risk standardizes the readmission rate for each hospital to adjust for underlying readmission risk, by condition, among hospitals. As these risk adjustment factors were developed with the Medicare population in mind, the HDMS adaptation does not currently include this specific form of risk-adjustment.
Implementation
Data needs:
CMS readmission logic is claims-based and requires complete enrollment files and medical claims with well-populated diagnosis codes to ensure accuracy and applicability. No additional data sources are required.
Timeline: The algorithm is integrated into our standard data processing and could be turned on as quickly as your next data refresh.
Business Need
Readmission events are costly, and often preventable through discharge instructions or coordinating care plans with the patient’s primary care provider(s). Under the 2010 Hospital Readmissions Reduction Program (HRRP), CMS restructured their hospital payment system to reduce readmission rates. In support of this program, CMS contracted YNHHSC to measure causes of unplanned readmission rates. It is anticipated that other health plans will restructure their hospital payment with a dependency on hospital readmission rates.