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Higher Readmission Penalties Linked to Low HCAHPS Scores

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   December 12, 2012

Hospitals that struggle with high rates of 30-day readmissions and fear federal penalties may look at their patient experience scores for clues on what might be driving their negative scores.

That's according to Press Ganey, which conducts Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys as required by the healthcare reform law's value-based purchasing regulations. The company found that hospitals that perform well on patient experience measures also have lower 30-day readmission rates and are least likely to receive a substantial readmission penalty.

But the opposite also is true, the survey company found. Hospitals that score the lowest in patient experience are most likely to be penalized the maximum 1% of their Medicare-base DRG, signaling that there may be a connection with leadership priorities and culture at those hospitals, says Nell Buhlman, Press Ganey's VP Product Strategy.

"What this study shows," adds Press Ganey CEO Patrick Ryan, "is that when one is focused on that patient experience, it has dramatic impact on your overall operating performance in a hospital."

For example, hospitals that did poorly, scoring between zero and 19 VBP points for answers patients gave to their HCAHPS survey questions, experienced a 0.4% reduction in Medicare payments, on average. While hospitals that scored in the highest brackets in HCAHPS survey questions, between 80 and 100 points, received on average a .1% readmissions penalty.

Ryan and Buhlman say the Press Ganey analysis, which they presented at the Institute for Healthcare Reform's 24th National Forum in Orlando this week, is the first time anyone has found a correlation between readmission penalties—the first of which kicked in with discharges Oct. 1, affecting up to 1% of Medicare DRG payments—and patient experience.

Press Ganey, which also consults with hospitals to improve patient experience scores, reviewed data for the two performance periods that CMS uses to determine value-based purchasing incentive payments and readmission penalties. For readmissions, Press Ganey used the rate of observed readmission from July 1, 2008 to June 30, 2011. 

For the value-based purchasing HCAHPS score performance, the company used the performance period from July 1, 2011 to March, 31, 2012, and used the points the hospital earned for performance compared with a baseline performance period, from July 1, 2009 to March 31, 2010.

The association between scores was only found with respect to HCAHPS, which is only 30% of the value-based purchasing score.  There was no correlation between readmission penalties and how the hospitals performed on the other 12 core clinical measures that make up 70% of the VBP incentive payment program.

That's probably because for most hospitals, performance on those core measures is already at 97, 98, 99 or 100%, "almost as good as you're going to get," Buhlman says.

On the other hand, hospital readmission rate scores vary from the very low end, with some hospitals receiving 0-19 points, some receiving 20 to 39 points, some 40-59, some 60-79 and some 80-100.

"What we see from the metrics that make up the various quality performance initiatives is the expectation that hospitals will extend their sphere of influence," Buhlman says.

She says there's a strong probability that the hospitals' focus on readmission rates also affects its relationship with the patient through communication, and that's why these patients give hospitals higher marks in patient experience.

"One of the things we coach hospitals on is communication, of course, directly  reflected in HCAHPS around discharge planning is that it's not one conversation that  occurs  the day the patient is being discharged," Buhlman explains. 

"You begin that conversation when the patient is admitted, and that conversation can be, 'Okay, Mrs. Jones, you're here to have your hip replaced. Typically that's a two-night stay in the hospital. So we're gunning for you to be discharged on Wednesday.' And literally, periodically throughout the stay, renewing that conversation," about who will be there to pick up the patient, about medication instructions, and other elements of care after the patient gets home.

"The patient is really engaged and has multiple opportunities to ask questions and understands what is expected of the patient upon discharge and what their individual responsibilities are," Buhlman says.

"Traditionally, the sphere of influence for hospitals was what happened on the campus and the walls of the hospital."

"When you have a leadership culture at the top that puts the patient experience as a top priority, that focuses on all the details of the patient experience, and as a result you're a high performing organization, the performance crosses the continuum...whether it's clinical, safety, patient experience, or even financial performance...they're at the higher end of the benchmarks of your peers, because you put the patient first," Ryan says.

With new components being added into the VBP measurement algorithm, "you see an efficiency of care domain that reflects spending per Medicare beneficiary from three days prior to admission to 30-days post discharge, so very much reflecting beyond the traditional sphere of influence within the hospital and the same is true with 30-day readmissions," she says.

The study also found that hourly rounding by nursing staff seems to be "the single most effective strategy for improving performance in patient experience."

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