Highlight on Missouri: hospital challenges readmission formula, says socioeconomics should factor in

Missouri-based Christian Hospital is challenging the way that Medicare calculates penalties for hospital readmissions. With the backing of the Missouri Hospital Association, the hospital asserts that Medicare’s Hospital Readmissions Reduction Program (HRRP) does not adequately account for the socioeconomic status of the patients that a hospital treats. The hospital and the hospital association argue that the methodology unfairly penalizes safety-net hospitals.


The HRRP, created by Section 3025 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), requires CMS to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions. CMS defines readmission as “an admission to a subsection (d) hospital within 30 days of a discharge from the same or another subsection (d) hospital.” CMS was obligated, under the program, to develop a formula to calculate an excessive readmission ratio based upon a national average of hospital performance. Medicare bases readmission penalties on the care of Medicare patients who were originally hospitalized for one of five conditions—heart attacks, heart failure, pneumonia, chronic lung problems, and elective hip or knee replacements. In 2015, the fourth year of the program, 2,592 hospitals were penalized due to high rates of readmissions. Overall, hospitals were penalized a total of $420 million last year.


Under current reimbursement rules, Christian Hospital is expecting to lose $600,000 in reimbursement due to what CMS deems “excessive readmissions.” However, the hospital believes the reimbursement penalty is improper because the formula used to derive the $600,000 figure does not factor in relevant socioeconomic disadvantages of certain patients. For example, the hospital believes that high numbers of patients with low-incomes, poor health habits, and chronic illnesses increased its readmission numbers. If CMS used readmission criteria that factored in those socioeconomic factors, Christian Hospital says its HRRP penalty would have been $140,000.

Missouri Hospital Association

The Missouri Hospital Association is putting its support behind Christian Hospital. The organization revamped its consumer-focused website, Focus on Hospitals, to include readmissions statistics that conform to the methodology Christian Hospital is asking CMS to use. The Focus on Hospitals website adjusts hospital readmission statistics in accordance with patients’ Medicaid status and neighborhood poverty rates. In support of its readmission statistic methodology, the hospital association says there is research that suggests “poverty and other community factors” increase the likelihood readmission to a hospital. The alternative data arises from a study commissioned by the Missouri Hospital Association. That study found that hospital readmission rates improved by between 44 and 88 percent when patients’ poverty levels were factored in.


In addition to avoiding penalties, together with the Missouri Hospital Association, Christian Hospital is hoping that its efforts will lead to changes in Medicare law. Specifically, Christina Hospital is seeking the kind of change envisioned by a piece of legislation known as “The Helping Hospitals Improve Patient Care Act.” The bill would alter the way socioeconomic status is considered under the HRRP. Specifically, the legislation would require a transitional risk-adjustment methodology to serve as a proxy of socio-economic status until a more refined methodology can be developed.


The concerns over the methodology echo similar complaints that hospitals have made about Medicare’s five-star rating system. Whether the issue is readmissions or ratings, interests are in conflict—CMS struggles to find a way to incentivize quality care while hospitals worry that they may be unfairly punished or penalized for treating certain populations. From the perspective of Christian Hospital in Missouri, the current balance is unfavorable.  But the question isn’t whether someone should be held accountable for unnecessary readmissions. The question is whether the scales are tipped unfairly.

HHS provides funding for training small practices in Quality Payment Program

HHS will provide $20 million in funding that will be used to train Medicare clinicians in small practices on the Quality Payment Program. These funds will be primarily directed toward clinicians practicing in underserved areas, including rural areas and health professional shortage areas. This amount of funding will be provided annually for the next five years.

Quality Payment Program

The proposed Quality Payment Program would implement the changes created by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which reformed clinician payment for serving Medicare patients. The proposal streamlined various value and quality programs into two paths. Under the program, physicians would be able to choose from the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs) (see Physician reporting streamlined, less burdensome under flexible Quality Payment Program, Health Law Daily, April 28, 2016).

Under MIPS, physicians would submit information about four performance categories. Then, a composite performance score is generated and compared against a threshold. This threshold determines the payment adjustment. Under APMs, physicians would receive a lump sum payment that could grow annually.

Small practices

Secretary Burwell emphasized the administration’s commitment to providing resources to small and rural practices that will allow them to provide quality care. Organizations must show that they are able to provide training to individual clinicians or small group practices of no more than 15 clinicians to become eligible for funding. The training would include creating a strategy for Quality Payment Program participation, such as adding electronic health record (EHR) capability, joining an APM, and evaluating practice workflow.

Largest mass shooting in U.S. history renews calls for changes to federal health policy

At 2:00 a.m. on Sunday, June 12, 2016, a man with an AR-15 assault rifle, a handgun, and another “device” walked into Pulse, a gay nightclub in Orlando, and carried out the deadliest mass shooting in American history. He killed 49 individuals, and wounded 53 others, before he was shot and killed by police.

According to Orange County Government Director of Health and Public Safety Dr. George Ralls, the nightclub’s location, approximately two blocks from Level 1 trauma center Orlando Regional Medical Center, where surgeons performed more than 30 surgeries on victims of the shooting, saved lives. Having a trauma center equipped to deal with the severe injuries inflicted, as well as resulting infections and other complications, is a “saving grace” for the tragedy, said Ralls.

Much of the public outcry following the attack is focused on whether the shooter was part of a terrorist organization or how the shooter was able to obtain the weapons. For public health advocacy groups, however, this tragedy is a reminder of federal laws and regulations which, they say, hinder their abilities to prevent similar massacres and properly treat patients in their aftermath.

Gun control research funding ban

In 1996, Rep. John Dickey (R-Ark) proposed an amendment to the omnibus consolidated appropriations act for fiscal year 1997 (P.L. 104-208) reading, “That none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention [CDC] may be used to advocate or promote gun control.” That same language has been included in each successful appropriations act passed since then; in 2011, the appropriations act for fiscal year 2012 expanded the funding ban to the National Institutes of Health (NIH) (P.L. 112-74). The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) includes an additional provision prohibiting HHS, health plans, and other databases from collecting information about firearm possession, use, or storage.

In a January 16, 2013, memorandum, President Barack Obama directed the HHS Secretary, through the Director of the CDC and other HHS scientific agencies to “conduct or sponsor research into the causes of gun violence and the ways to prevent it.” However, no funding has been appropriated to the research, and the CDC has not taken any action.

There have been multiple calls to end the research ban. In April 2016, a letter to the leaders of the Senate and House appropriations committees from 141 health care, public health, and scientific organizations asked Congress to provide the CDC with funding for research into the causes and prevention of gun violence. At the end of May 2016, Democrat members of the House of Representatives signed a letter asking House leadership to remove amendments freezing gun violence research from future appropriations bills.

Two days after the Pulse shooting, the American Medical Association (AMA) announced that the organization, the largest association of physicians and medical students in the United States and one of the signatories of the April 2016 letter, will actively lobby Congress to overturn the research ban. Calling gun violence a public health crisis, AMA President Steven J. Stack, M.D. said, “Even as America faces a crisis unrivaled in any other developed country, the Congress prohibits the CDC from conducting the very research that would help us understand the problems associated with gun violence and determine how to reduce the high rate of firearm-related deaths and injuries. An epidemiological analysis of gun violence is vital so physicians and other health providers, law enforcement, and society at large may be able to prevent injury, death and other harms to society resulting from firearms.”

FDA blood donor policy

When the HIV/AIDS epidemic began over 30 years ago, the FDA implemented a lifetime ban on blood donations from men who have sex with men (MSM), regardless of risk factors. Since at least 1997, the American Association of Blood Banks, the Red Cross, and America’s Blood Centers have advocated revising the policy and removing the lifetime ban because advances in blood screening technology and the scientific community’s increasing understanding of the HIV/AIDS virus rendered the ban medically and scientifically unwarranted. HHS convened a non-partisan group of scientific experts in 2010 for the Advisory Committee on Blood Safety and Availability. The Committee concluded that the lifetime ban should be changed because it prohibits low-risk donors from giving blood, but allows donations from high-risk individuals.

The FDA updated its policy in a December 23, 2014, announcement from then-Commissioner Margaret Hamburg, M.D. The change lifted the lifetime ban on blood donations from MSM, permitting donations if at least one year has elapsed since the donor’s last sexual contact with another man. The FDA noted  that the new policy, which went into effect in December 2015, would align blood centers’ treatment of MSM more closely to the treatment of other individuals who have engaged in behaviors that increase their risk of AIDS.

This change was met with mixed reactions. Responses to ending the lifetime ban have generally been positive, however, the 12-month deferral excludes many men who are in monogamous relationships and present no risk of HIV transmission while not deferring donations from women who have had many sexual partners, unless they are prostitutes.

In the wake of the Pulse shooting, people all over Florida, including many members of the LGBTQ community, rushed to donate blood to meet the needs of the injured victims. Due to the FDA policy, many would-be donors were turned away. Over 100 bipartisan members of the House and 24 bipartisan members of the Senate sent letters to FDA Commissioner Robert A. Califf, M.D., asking for an update on implementation of the 12-month deferral policy, and expressing their hopes that the agency will continue moving toward a less discriminatory and more science-based policy.

New focus, more funding for improving transplant process, organ viability

A number of organizations, including the White House, have united to improve the process for organ transplants in hopes of reducing the time recipients must wait for the life-saving opportunity they so desperately need.  At the White House Organ Summit, the administration announced what steps these organizations will take to improve the donor process, which includes a $160 million program led by the Department of Defense to develop cell repair and replacement techniques.

Registration: Is opt-in the best strategy?

Although 95 percent of the American population supports organ donation, only half are registered as organ donors. This is one thing the united organizations hope to change. Over 120,000 hopeful recipients are on the waiting list, with nearly 100,000 of those needing kidneys. The wait is deadly, taking 22 lives per day.

The registration process, as it stands, leaves something to be desired. Donors must opt in at their Department of Motor Vehicles (DMV). In other countries, opt-out policies result in much higher registration levels. Although some have expressed concern about presuming consent, the high support rate indicates that most would not object to such a change. Social media companies have committed to a campaign to encourage people to declare themselves donors online instead of through the DMV.

Maintaining viability

One way to increase the successful use of donated organs is coming up with ways to preserve viability during transport. Toting an organ in a cooler packed with ice, as seen on television shows, is not the best strategy. A device that monitors the organ while maintaining its temperature and infusing it with oxygenated blood can help the organ to start functioning almost as soon as it is transplanted.

Cooling the organ slows its natural processes down, but the approach of keeping it warm allows it to continue functioning. Trials established the safety of the technique for hearts and lungs, but it had not been proven for the liver–yet a successful transplant indicates that it will work. Many potential donor hearts are unusable because putting them on ice would cause too much damage. A study is currently underway to determine if warm transport will alleviate this issue.

The device, developed by TransMedics, is a plastic box that can be manipulated as needed. It can attach to a cart or be removed to fit into a transport vehicle. Warmed blood and nutrients are pumped through while sensors monitor functions. Various conditions can be altered on a control screen. The device is awaiting FDA approval for commercial use, but it is already being used in the other parts of the world. Even if this option is successful, however, the device may be prohibitively expensive for payers.

In  the meantime, other efforts to improve the entire process are underway. Over 30 transplant centers have agreed to share data about kidney transplants, while Johns Hopkins University and the National Institute of Allergy and Infectious Disease are working together to expand HIV-positive donor options. The FDA and the American Society of Nephrology will work together to create alternatives to kidney dialysis. The government is also improving the online platform for matching, labeling, and tracking organs in order to reduce the burden on hospitals and speed up the process.

Creating an organ

Another approach to the organ shortage is developing new organs altogether. The Pentagon is creating the Advanced Tissue Biofabrication Manufacturing Innovation Institute to develop a process for generating new human cells and tissues. The National Cell Manufacturing Consortium and others are collaborating to best decide how to develop this technology. The idea of tissue engineering is not a new one, and the National Institutes of Health (NIH) has been involved in research to create tissues and expand human application. The new institute will hopefully build on these efforts and result in many more lives saved.