Kusserow’s Corner: Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring

The HHS Office of Inspector General (OIG) Office of Evaluation and Inspection (OEI) released a report (OEI-06-11-00040) involving nursing homes hospitalize residents that are determined to require transfers to hospitals provide residents with access to needed acute-care services. These decisions are made by physicians and nursing staff at the nursing homes. The OIG was concerned that these hospitalizations are not only costly to Medicare, but that transfers between settings increase the risk to residents and other negative care outcomes. They also believed that high rates of hospitalizations by individual nursing homes could signal quality problems within those homes.

The OIG used administrative and billing data both for nursing homes and hospitals to identify all Medicare residents in Medicare or Medicaid certified nursing homes that experienced transfers to hospitals for inpatient stays. They included all Medicare-paid skilled nursing and rehabilitative (SNF) stays and those in nursing home stays not paid for by Medicare, which include long-term care (LTC) stays. They calculated the percentage of Medicare nursing home residents that each nursing home hospitalized. They identified the diagnoses associated with these hospitalizations, calculated Medicare reimbursements for the hospital stays, and calculated the rates and costs of hospitalizations of nursing home residents. They also examined the extent to which annual rates of resident hospitalizations varied among individual nursing homes.

They found, during the period reviewed, that nursing homes transferred one quarter of their Medicare residents to hospitals for inpatient admissions, costing Medicare $14.3 billion. Nursing home residents went to hospitals for a wide range of conditions, with septicemia the most common. Annual rates of Medicare resident hospitalizations varied widely across nursing homes.

Nursing homes with the following characteristics had the highest annual rates of resident hospitalizations:

  • Those located in Arkansas, Louisiana, Mississippi, or Oklahoma; and
  • Those with one, two, or three stars in the CMS Five-Star Quality Rating System

The OIG made recommendation and CMS concurred with them that included:

  1. Develop a quality measure that describes nursing home resident hospitalization rates; and
  2. Instruct State survey agencies to review the proposed quality measure as part of the survey and certification process.

Based upon this report, it is likely that greater attention will be provided to the states identified and for those homes with lower ratings. For more information on this subject, the OIG has prepared a Podcast to discuss the issue.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2013 Strategic Management Services, LLC. Published with permission.