Goal: Exempt Sickle Cell Disease
This diagnosis should be exempt from Medicaid penalty
By the CMS Student Section
As public health care systems experiment with methods to reduce medical spending, one target has been readmissions to the hospital within 30 days of discharge. The Centers for Medicare and Medicaid Services (CMS) increasingly links hospital outcomes to payment.
At the state level, Illinois passed the “Save Medicaid Access and Resources Together Act” (SMART Act) in June 2012. The Act established benchmarks to measure and align hospital payments, with the goal of reducing potentially preventable hospital readmissions. The SMART Act penalizes hospitals for discharging patients who are subsequently readmitted to an inpatient setting within 30 days and have a condition clinically related to the original admission. Unlike Medicare, which initially focused on a select few high-volume, high-cost medical conditions, Medicaid targets all hospital admissions with few exemptions.
In budget-strapped Illinois, the goals of the program make sense. Yet for safety net hospitals, and the populations they serve, these penalties can have adverse implications. The frequent readmission of patients with a sickle cell diagnosis is a case in point.
The Illinois Department of Healthcare and Family Services (DHFS) uses 3M’s proprietary Potentially Preventable Readmissions software to calculate both actual rates and target rates based on several factors. The methodology determines whether a readmission is potentially preventable and also determines a hospital’s financial penalty. Certain diagnoses, such as HIV, are exempt from the 3M software analysis, due to the complexity of care and low likelihood that readmission can be prevented. Unfortunately, sickle cell disease is not an exempt diagnosis.
Readmissions Part of Treatment
Pain crises account for more than 90% of hospital admissions for sickle cell patients, according to multiple studies. One study of adult patients in Illinois found that the admitting diagnosis was painful crisis in 97.4% of the cases. Pain crises are unpredictable and can be triggered by a number of factors. Stress—traumatic, physical, psychological, or physiological—can bring on pain crises, and involve any part of the body with varying severity and duration. To a large extent, pain crises lead to the frequent hospital readmissions seen in sickle cell patients. Because frequent readmissions are part of the treatment for sickle cell disease, hospitals open themselves up to penalties through the SMART Act.
These concerns were the impetus for a resolution to the Chicago Medical Society (CMS). After giving testimony, the student sponsors of the resolution saw their measure gain support. In addition to writing to DHFS, requesting an exemption of sickle cell disease from the readmission penalties, CMS will ask ISMS to pursue legislation to exempt sickle cell disease from the SMART Act readmission penalties.
Sickle cell disease is a lifelong genetic condition that results in chronic use of the health care system. In a five-year longitudinal prospective study at Thomas Jefferson University Hospital, patients averaged over two hospital admissions per year, with the mean length of stay of 7.7 days. About half of all hospital readmissions for sickle cell patients occurred within one month of discharge. An analysis of Medicaid claims for hospital discharges with a diagnosis of sickle cell disease reported a median of 1.5 admissions per year per patient, with a mean length of stay of 5.9 days and a 30-day readmission rate of 39.6%.
Patients with sickle cell disease are medically vulnerable. The vast majority are African-American, many on public insurance. 3M’s software establishes a target PPR hospital rate and adjusts it only for patient age and behavioral health. The 3M software does not account for socioeconomic factors, including discontinuity in coverage, low literacy, language barriers, lack of transportation, unstable housing, unstable employment, and poverty.
The 30-day readmission penalty is of particular importance for the Chicago area. A study of adult patients in Illinois with sickle cell disease found that 85% live in the Chicago metropolitan area; 67% of Chicago patients had Medicaid or Medicare insurance. The metropolitan areas of Chicago and East St. Louis account for more than 90% of sickle cell admissions statewide. Over 50% of admissions are to safety net hospitals.
Balancing Vigilance with Value
A dominant theme in health care policy has been how to transition from a procedure-based system to a value-based one. This is an admirable and difficult goal for legislators, researchers, and health systems to tackle. But as changes are made in the formulas for medical reimbursement, providers should remain vigilant that unintended consequences do not negatively impact patient health.
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