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Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy

      Abstract

      OBJECTIVE

      To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts.

      MATERIALS AND METHODS

      Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate.

      RESULTS

      Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non–readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%.

      CONCLUSION

      Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.
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      References

        • Leow JJ
        • Cole AP
        • Seisen T
        • et al.
        Variations in the costs of radical cystectomy for bladder cancer in the USA.
        Eur Urol. 2017; 73: 374-382
        • Novara G
        • Catto JWF
        • Wilson T
        • et al.
        Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy.
        Eur Urol. 2015; https://doi.org/10.1016/j.eururo.2014.12.007
        • Skolarus TA
        • Jacobs BL
        • Schroeck FR
        • et al.
        Understanding hospital readmission intensity after radical cystectomy.
        J Urol. 2015; https://doi.org/10.1016/j.juro.2014.10.107
        • Hu M
        • Jacobs BL
        • Montgomery JS
        • et al.
        Sharpening the focus on causes and timing of readmission after radical cystectomy for bladder cancer.
        Cancer. 2014; https://doi.org/10.1002/cncr.28586
        • Stitzenberg KB
        • Chang YK
        • Smith AB
        • Nielsen ME
        Exploring the burden of inpatient readmissions after major cancer surgery.
        J Clin Oncol. 2015; https://doi.org/10.1200/JCO.2014.55.5938
        • Jenq GY
        • Doyle MM
        • Belton BM
        • Herrin J
        • Horwitz LI
        Quasi-experimental evaluation of the effectiveness of a large-scale readmission reduction program.
        JAMA Intern Med. 2016; https://doi.org/10.1001/jamainternmed.2016.0833
        • Desai NR
        • Ross JS
        • Kwon JY
        • et al.
        Association between hospital penalty status under the hospital readmission reduction program and readmission rates for target and nontarget conditions.
        JAMA. 2016; 316: 2647-2656https://doi.org/10.1001/jama.2016.18533
        • Mehtsun WT
        • Papanicolas I
        • Zheng J
        • Orav EJ
        • Lillemoe KD
        • Jha AK
        National trends in readmission following inpatient surgery in the hospital readmissions reduction program era.
        Ann Surg. 2018; https://doi.org/10.1097/SLA.0000000000002350
        • Clement RC
        • Gray CM
        • Kheir MM
        • et al.
        Will medicare readmission penalties motivate hospitals to reduce arthroplasty readmissions?.
        J Arthroplasty. 2017; https://doi.org/10.1016/j.arth.2016.08.031
        • Lee R
        • Ng CK
        • Shariat SF
        • et al.
        The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy.
        BJU Int. 2011; https://doi.org/10.1111/j.1464-410X.2011.10114.x
        • Li P
        • Kim MM
        • Doshi JA
        Comparison of the performance of the CMS hierarchical condition ategory (CMS-HCC) risk adjuster with the Charlson and Elixhauser comorbidity measures in predicting mortality.
        BMC Health Serv Res. 2010; https://doi.org/10.1186/1472-6963-10-245
      1. Hospital Rreadmissions Reduction Program (HRRP) Archives.
        2018 (Published 2018. Accessed April 2 2019)
        • Borza T
        • Oerline MK
        • Skolarus TA
        • et al.
        Association of the hospital readmissions reduction program with surgical readmissions.
        JAMA Surg. 2018; https://doi.org/10.1001/jamasurg.2017.4585
      2. Draft ICD-10-CM/PCS MS-DRGv28 Definitions Manual: Appendix C Complications or Comorbidities Exclusion list. https://www.cms.gov/icd10manual/fullcode_cms/p0031.html. Accessed April 2, 2019.

        • Eappen S
        • Lane BH
        • Rosenberg B
        • et al.
        Relationship between occurrence of surgical complications and hospital finances.
        JAMA. 2013; https://doi.org/10.1001/jama.2013.2773
        • Mittal M
        • Wang CHE
        • Goben AH
        • Boyd AD
        Proprietary management and higher readmission rates: a correlation.
        PLoS One. 2018; https://doi.org/10.1371/journal.pone.0204272
        • Ibrahim AM
        • Dimick JB
        • Sinha SS
        • Hollingsworth JM
        • Nuliyalu U
        • Ryan AM
        Association of coded severity with readmission reduction after the hospital readmissions reduction program.
        JAMA Intern Med. 2018; 178: 290-292https://doi.org/10.1001/jamainternmed.2017.6148
        • Krishnan N
        • Li B
        • Jacobs BL
        • et al.
        The fate of radical cystectomy patients after hospital discharge: understanding the black box of the pre-readmission interval.
        Eur Urol Focus. 2016;
        • Centers for Medicare & Medicaid Services
        Hospital-Wide All-Cause Unplanned Readmission Measure (HWR).
        Centers for Medicare and Medicaid Services in Baltimore, MD2018
        • Jha AK
        Seeking rational approaches to fixing hospital readmissions.
        JAMA. 2015; 314: 1681-1682https://doi.org/10.1001/jama.2015.13254
        • Barnett ML
        • Hsu J
        • McWilliams JM
        Patient characteristics and differences in hospital readmission rates.
        JAMA Intern Med. 2015; 175: 1803-1812https://doi.org/10.1001/jamainternmed.2015.4660
        • Minnillo BJ
        • Maurice MJ
        • Schiltz N
        • et al.
        Few modifiable factors predict readmission following radical cystectomy.
        Can Urol Assoc J. 2015; https://doi.org/10.5489/cuaj.2793
        • Singh JA
        • Yu S
        • Chen L
        • Cleveland JD
        Rates of total joint replacement in the United States: future projections to 2020-2040 using the national inpatient sample.
        J Rheumatol. 2019; https://doi.org/10.3899/jrheum.170990
        • Alexander JH
        • Smith PK
        Coronary-artery bypass grafting.
        N Engl J Med. 2016; https://doi.org/10.1056/NEJMra1406944
        • Gupta A
        • Allen LA
        • Bhatt DL
        • et al.
        Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure.
        JAMA Cardiol. 2018; https://doi.org/10.1001/jamacardio.2017.4265
        • Leow JJ
        • Gandaglia G
        • Sood A
        • et al.
        Readmissions after major urologic cancer surgery.
        Can J Urol. 2015; https://doi.org/10.1016/j.polymer.2017.06.076
        • Weiss ME
        • Yakusheva O
        • Bobay KL
        • et al.
        Effect of implementing discharge readiness assessment in adult medical-surgical units on 30-day return to hospital: the READI randomized clinical trial.
        JAMA Netw Open. 2019; 2: e187387https://doi.org/10.1001/jamanetworkopen.2018.7387
        • Krishnan N
        • Liu X
        • Lavieri MS
        • et al.
        A model to optimize followup care and reduce hospital readmissions after radical cystectomy.
        J Urol. 2016; https://doi.org/10.1016/j.juro.2015.11.063
        • Helm JE
        • Alaeddini A
        • Stauffer JM
        • Bretthauer KM
        • Skolarus TA
        Reducing hospital readmissions by integrating empirical prediction with resource optimization.
        Prod Oper Manag. 2016; https://doi.org/10.1111/poms.12377
        • Liu X
        • Hu M
        • Helm JE
        • Lavieri MS
        • Skolarus TA
        Missed opportunities in preventing hospital readmissions: redesigning post-discharge checkup Policies.
        Prod Oper Manag. 2018; https://doi.org/10.1111/poms.12858