Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-2 - Hospital Services
Section 5160-2-14 - Potentially preventable readmissions
Universal Citation: OH Admin Code 5160-2-14
Current through all regulations passed and filed through September 16, 2024
(A) General provisions.
(1)
All hospitals that are subject to the all patient refined
diagnosis related groups (APR-DRG) prospective payment methodology utilized by
the Ohio department of medicaid as defined in rule
5160-2-65 of the Administrative
Code are subject to the potentially preventable readmissions (PPR) provisions
set forth in this rule.
(2)
Hospitals that have twenty or more medicaid discharges
in the reporting year as described in paragraph (D) of this rule are subject to
a PPR rate adjustment as described in paragraph (E) of this
rule.
(3)
PPR hospital report cards are available on the
department's website at medicaid.ohio.gov. Report cards will be updated
biannually with the most current claims data as defined in this
rule.
(B) Definitions.
(1)
"Potentially
preventable readmission (PPR)" is an inpatient readmission that meets all of
the readmission criteria set forth in paragraph (C) of this rule, that follows
a prior discharge from a hospital within thirty days and that is deemed
clinically-related and clinically-preventable to the initial admission by the
PPR software.
(2)
"PPR software" is the "3M Health Information Systems"
grouping software used to determine or group clinically-related and
clinically-preventable inpatient hospital admissions.
(3)
"Actual PPR rate"
is the PPR rate computed as total clinically-related readmission chains as
described in paragraph (B)(3)(a) of this rule, divided by the sum of initial
admissions as described in paragraph (B)(3)(b) of this rule and only admissions
as described in paragraph (B)(3)(c) of this rule.
(a)
"Clinically-related readmission chain" is a series of
admissions for the same patient where the underlying reason for readmission is
related, as determined by the PPR software, to the care rendered during or
within thirty days following a prior hospital admission. A clinically-related
readmission may have resulted from improper or incomplete care during the
initial admission or discharge planning process. The hospital where the initial
admission occurred is responsible for the clinically-related readmission chain.
Hospitalization resulting from an unpreventable or unrelated event occurring
after discharge and planned readmissions are not considered
clinically-related.
(b)
"Initial admission" is an admission that is followed by
a clinically-related readmission within the thirty day readmission
period.
(c)
"Only admission" is an admission where there was
neither a prior initial admission nor a clinically-related readmission within
the thirty day readmission period.
(4)
"Expected PPR
rate" is the PPR rate computed as total clinically-related readmission chains
as described in paragraph (B)(3)(a) of the rule divided by the sum of initial
admissions as described in paragraph (B)(3)(b) of this rule and only admissions
as described in paragraph (B)(3)(c) of this rule.
The expected PPR rate is adjusted for severity of illness and risk of mortality by converting actual total clinically-related readmission chains into expected total clinically-related readmission chains by factoring in for each hospital its mix of adult and pediatric cases by DRG when compared to the statewide mix. Patients with a mental health comorbidity are also considered in the expected PPR rate when compared to the statewide mix.
(5)
"Actual-to-expected ratio" is the actual PPR rate as
described in paragraph (B)(3) of this rule divided by the expected PPR rate as
described in paragraph (B)(4) of this rule.
(6)
"Claims data"
consists of fee-for-service claims and managed care claims
data.
(7)
"PPR rate adjustment" is a modification in the
hospital's base rate as described in paragraph (E) of this
rule.
(C) Readmission criteria.
(1)
A readmission is
a return hospitalization within thirty days of a prior discharge that meets all
of the following criteria:
(a)
The readmission is potentially preventable by the
provision of appropriate care consistent with accepted care standards, based on
the PPR software, in the prior discharge or during the post-discharge follow-up
period.
(b)
The readmission is for a condition or procedure that is
clinically-related to the care provided during the prior discharge or resulting
from inadequate discharge planning during the prior discharge.
(c)
The PPR chain may
contain one or more readmissions that are clinically-related to the initial
admission. If the first readmission is within thirty days after the initial
admission, the thirty day timeframe may begin again at the discharge of either
the initial admission or the most recent readmission clinically-related to the
initial admission.
(d)
The readmission is to the same or to any other
hospital.
(2)
Readmissions, for the purposes of determining PPRs,
excludes the following circumstances:
(a)
The original
discharge was a patient initiated discharge, was against medical advice (AMA),
and the circumstances of such discharge and readmission are documented in the
patient's medical record.
(b)
The original discharge was for the purpose of securing
treatment of a major or metastatic malignancy, major trauma, neonatal and
obstetrical admission, transplant, HIV, and non-events as defined by the PPR
software.
(c)
Only admissions, which are defined by the PPR software
and described in paragraph (B)(3)(c) of this rule. Planned readmissions are
considered "only admissions" by the PPR software.
(D) Methodology to determine excess readmissions for calendar year 2017 and thereafter.
(1)
Rate adjustments for calendar year 2017 for each
hospital shall be based on each hospital's paid claims data for discharges that
occurred on July 1, 2014 through June 30, 2015. For each calendar year
thereafter, rate adjustments shall be based on each hospital's paid claims data
from the state fiscal year ending the calendar year preceding the calendar year
immediately preceding the effective date of the PPR rate
adjustment.
(2)
Excess readmission rates are calculated by dividing the
hospital's actual PPR rate by the hospital's expected PPR rate.
(a)
An
actual-to-expected ratio as described in paragraph (B)(5) of this rule of one
indicates that the hospital had readmissions within thirty days at a rate that
is expected given their patient mix.
(b)
An
actual-to-expected ratio as described in paragraph (B)(5) of this rule of less
than one indicates that the hospital had less readmissions within thirty days
than is expected given their patient mix.
(c)
An
actual-to-expected ratio as described in paragraph (B)(5) of greater than one
indicates that the hospital had more readmissions within thirty days than is
expected given their patient mix.
(E) PPR rate adjustment.
(1)
A hospital with excess readmissions defined as greater than
one is subject to a reduction of their inpatient hospital-specific base rate
equal to one per cent.
(2)
The excess readmission penalty will be applied on
January first of each calendar year and will remain in effect for that calendar
year.
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