Becker's Hospital Review

26 Executive Briefing: Bundled Payments Looking at the most expensive region in the DataGen study, acute-care transfers of patients in an AMI DRG occurred 36 per- cent of the time and, among those transfers, almost half received a PCI at the second hospital; that is, 17.5 percent of the AMI epi- sodes in the most expensive region were transferred for a PCI (Figure 2). For those episodes, the average length of stay for the initial inpatient stay was just less than three days — these were not one-day stays where the patient was stabilized and immedi- ately transferred out. Upon identifying that patient transfers for PCIs were driving signif- icant payment variation, the DataGen research team initially as- sumed that inpatient PCIs were more commonly performed in the most expensive region than in the least expensive region. Further analysis revealed that the opposite is actually true. Sixty-five per- cent of the episodes with a principal diagnosis of AMI in the least expensive region, Billings/Casper, received an inpatient PCI, ei- ther during the initial stay or in a subsequent admission; in the most expensive region, Cape May, that percentage is 44 percent. Next, DataGen examined whether transfers were more likely from hospitals that do not perform PCIs. Surprisingly, the data indicate that in numerous instances, hospitals with the capability to perform PCIs are still transferring some of their heart attack patients to other hospitals. Finally, these same regions with higher volumes of transfers also see significantly higher payments for readmissions, SNF and home health care — the subsequent in- terventions are not saving enough costs downstream to offset the additional upfront costs. Opportunities for efficiency in treating AMI patients When looking to redesign patient care for improved outcomes, cost-effectiveness and efficiency, the intent is to provide services to and payment for patient-centered care. Looking at the AMI epi- sodes of care, there are clear opportunities to reduce costs by ensuring that patients are treated in the most appropriate setting. There are three scenarios for care based on the AMI findings: • In hospitals that are licensed to perform PCIs, a patient who is admitted with AMI and needs a PCI receives his or her full treatment at that hospital. This results in one DRG assign- ment and payment for the PCI. • In hospitals not licensed to perform PCIs, a patient admitted with an AMI who needs a PCI will be designated as an AMI DRG at the first hospital and then be transferred to another hospital for the PCI. This results in two DRG payments, one for the AMI care and one for the PCI. In this case, the inpa- tient acute-care costs of the patient's episode of care are doubled. • In hospitals that are licensed to perform PCIs, a patient who is admitted with an AMI and needs a PCI receives some care at the first hospital and then is transferred to another hospital for the PCI. This also results in two DRG payments and twice the inpatient acute-care cost. $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Medicare Average FFS Costs for 90-Day AMI Episodes - 2012 Anchor Admission Acute Transfer Readmission Inpatient Rehab Home Health Outpatient Professional Skilled Nursing facility Inpatient Psych Long Term Care Hospital Figure 2 Surprisingly, the data indicate that in numerous instances, hospitals with the capability to perform PCIs are still transferring some of their heart attack patients to other hospitals.

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