The Conservative Case for Obamacare

[dblack]

Repeating this doesn't make it any more rational. "Excess" readmissions are establish merely by the number of readmissions.

No, they're not. Two hospitals with identical readmissions numbers but different patient mixes don't have the same proportion of excess readmissions.

Though I do enjoy how "Some are. Some aren't." quickly morphed into "Every single readmission a hospital might have could be justifiable."

I retain hope that in the future we can have informed consumers who'll be able to use and interpret publicly reported validated quality indicators to make good decisions when shopping for health care services. But it's conversations like this that make me wonder if that's ever really going to be possible.

So, I'm curious. Were you ever trying to make sense? Or is this all just a baffle them with bullshit strategem? You're not even following my argument, much less refuting it. Seriously, if you're not going to pay attention, or even try to make any sense, you might as well use pretty colors like Mr. Shaman.

 

[Greenbeard]

So, I'm curious. Were you ever trying to make sense? Or is this all just a baffle them with bullshit strategem? You're not even following my argument, much less refuting it. Seriously, if you're not going to pay attention, or even try to make any sense, you might as well use pretty colors like Mr. Shaman.

I get it. You have an irrational aversion to elites and math and anything else that goes into gauging quality at a large and complex institution. Poor performance on validated quality measures is meaningless to your decision-making because you can rationalize every single quality lapse and, as a bonus, also lash out in your impotent rage at government (sorry, "benevolent overlords").

This is a microcosm of why we waste so much money every year on shitty service. We're gluttons for punishment!

 

[dblack]

This is a microcosm of why we waste so much money every year on shitty service. We're gluttons for punishment!

Finally, something that makes sense. Agreed.

 

[Quantum Windbag]

So, I'm curious. Were you ever trying to make sense? Or is this all just a baffle them with bullshit strategem? You're not even following my argument, much less refuting it. Seriously, if you're not going to pay attention, or even try to make any sense, you might as well use pretty colors like Mr. Shaman.

I get it. You have an irrational aversion to elites and math and anything else that goes into gauging quality at a large and complex institution. Poor performance on validated quality measures is meaningless to your decision-making because you can rationalize every single quality lapse and, as a bonus, also lash out in your impotent rage at government (sorry, "benevolent overlords").

This is a microcosm of why we waste so much money every year on shitty service. We're gluttons for punishment!

That was funny.

I actually dug into the language regarding readmissions and it turns out you are misrepresenting what it says, why is that? While it is true that hospitals will face different repercussions based on their patient ratios, that is only because the regulation requiring hospitals to adjust their readmission policy only applies to patients covered by CMS. All readmissions under CMS have to meet an arbitrary statistical level that does not consider anything but the percentage. It doesn't matter if the the readmission is justified or unjustified, all that matters is if it occurs.

This causes a great deal of concern to quite a few health economists, something you obviously know next to nothing about, because it will adversely impact safety net hospitals which have a higher percentage of CMS patients. This will result in disparate impact on minority populations, which concerns the idiots that think health care is a right. This will also impact at risk populations, like AIDS patients, and others with chronic conditions, which concerns everyone that actually cares about health care.

Why are you, the self declared expert on health care economics, not concerned about these things?

My guess, you are a lying sack of shit partisan hack.

 

[dblack]

That was funny.

I actually dug into the language regarding readmissions and it turns out you are misrepresenting what it says, why is that? While it is true that hospitals will face different repercussions based on their patient ratios, that is only because the regulation requiring hospitals to adjust their readmission policy only applies to patients covered by CMS. All readmissions under CMS have to meet an arbitrary statistical level that does not consider anything but the percentage. It doesn't matter if the the readmission is justified or unjustified, all that matters is if it occurs.

Yeah... I've put this under his nose at least five times now and he just steers right around it like it's not even there. Best of luck in your efforts though.

 

[Greenbeard]

I actually dug into the language regarding readmissions and it turns out you are misrepresenting what it says, why is that? While it is true that hospitals will face different repercussions based on their patient ratios, that is only because the regulation requiring hospitals to adjust their readmission policy only applies to patients covered by CMS. All readmissions under CMS have to meet an arbitrary statistical level that does not consider anything but the percentage.

Not so. The reason the same proportion of readmissions for different patient populations scores differently across hospitals is that the measure is risk-adjusted. Varying risk factors for the patient populations treated across hospitals are built into the measure specifications. CMS is using three NQF-endorsed quality measures in the first phase of the program. For instance, see the AMI readmissions indicator:

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we are using this field to define our statistically-adjusted outcome measure.

Hierarchical logistic regression modeling is used to calculate a hospital-specific RSRR. The RSRR is calculated as the ratio of the number of "predicted" to the number of "expected" readmissions, multiplied by the national unadjusted readmission rate. For each hospital, the "numerator" of the ratio is the number of readmissions within 30 days predicted on the basis of the hospital's performance with its observed case mix, and the "denominator" is the number of readmissions expected on the basis of the nation's performance with that hospital's case mix. This approach is analogous to a ratio of "observed" to "expected" used in other types of statistical analyses. It conceptually allows for a comparison of a particular hospital's performance given its case-mix to an average hospital's performance with the same case mix. Thus a lower ratio indicates lower-than-expected readmission or better quality and a higher ratio indicates higher-than-expected readmission or worse quality.

The predicted hospital outcome (the numerator) is calculated by regressing the risk factors and the hospital-specific intercept on the risk of readmission, multiplying the estimated regression coefficients by the patient characteristics in the hospital, transforming, and then summing over all patients attributed to the hospital to get a value. The expected number of readmissions (the denominator) is obtained by regressing the risk factors and a common intercept on the readmission outcome using all hospitals in our sample, multiplying the subsequent estimated regression coefficients by the patient characteristics observed in the hospital, transforming, and then summing over all patients in the hospital to get a value.

 

[dblack]

See? Ididnit something?

I keep thinking of those old Mr. Magoo cartoons.

 

[Quantum Windbag]

I actually dug into the language regarding readmissions and it turns out you are misrepresenting what it says, why is that? While it is true that hospitals will face different repercussions based on their patient ratios, that is only because the regulation requiring hospitals to adjust their readmission policy only applies to patients covered by CMS. All readmissions under CMS have to meet an arbitrary statistical level that does not consider anything but the percentage.

Not so. The reason the same proportion of readmissions for different patient populations scores differently across hospitals is that the measure is risk-adjusted. Varying risk factors for the patient populations treated across hospitals are built into the measure specifications. CMS is using three NQF-endorsed quality measures in the first phase of the program. For instance, see the AMI readmissions indicator:

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we are using this field to define our statistically-adjusted outcome measure.

Hierarchical logistic regression modeling is used to calculate a hospital-specific RSRR. The RSRR is calculated as the ratio of the number of "predicted" to the number of "expected" readmissions, multiplied by the national unadjusted readmission rate. For each hospital, the "numerator" of the ratio is the number of readmissions within 30 days predicted on the basis of the hospital's performance with its observed case mix, and the "denominator" is the number of readmissions expected on the basis of the nation's performance with that hospital's case mix. This approach is analogous to a ratio of "observed" to "expected" used in other types of statistical analyses. It conceptually allows for a comparison of a particular hospital's performance given its case-mix to an average hospital's performance with the same case mix. Thus a lower ratio indicates lower-than-expected readmission or better quality and a higher ratio indicates higher-than-expected readmission or worse quality.

The predicted hospital outcome (the numerator) is calculated by regressing the risk factors and the hospital-specific intercept on the risk of readmission, multiplying the estimated regression coefficients by the patient characteristics in the hospital, transforming, and then summing over all patients attributed to the hospital to get a value. The expected number of readmissions (the denominator) is obtained by regressing the risk factors and a common intercept on the readmission outcome using all hospitals in our sample, multiplying the subsequent estimated regression coefficients by the patient characteristics observed in the hospital, transforming, and then summing over all patients in the hospital to get a value.

Still don't see anything in there about them actually determining if a discharge was advisable for medical or personal reason, all they care about is not paying for sick people with preexisting conditions to go back into the hospital.

 

[Quantum Windbag]

See? Ididnit something?

I keep thinking of those old Mr. Magoo cartoons.

It is amazing.

 

[Greenbeard]

Still don't see anything in there about them actually determining if a discharge was advisable for medical or personal reason, all they care about is not paying for sick people with preexisting conditions to go back into the hospital.

We're just moving past the part where you flat out lied by saying each measure "does not consider anything but the percentage" then? And the bit where you flat out lied about "digging into the language" for that matter?

 

[Quantum Windbag]

Still don't see anything in there about them actually determining if a discharge was advisable for medical or personal reason, all they care about is not paying for sick people with preexisting conditions to go back into the hospital.

We're just moving past the part where you flat out lied by saying each measure "does not consider anything but the percentage" then? And the bit where you flat out lied about "digging into the language" for that matter?

Do you know what hierarchical logistic regression modeling is?

 

[Listening]

Some are. Some aren't. Some save money by avoiding unnecessary time in the hospital. Once again, you're faced with the fact the the regulatory approach doesn't make this distinction. You should probably just skip this.

Reducing payment for excess readmissions does make that distinction.

Repeating this doesn't make it any more rational. Under the policy in question, "excess" readmissions are established merely by the number of readmissions. It doesn't matter whether they are preventable or unnecessary. Every single readmission a hospital might have could be justifiable but, if the total number exceeded the established maximum, they would still be penalized. That's the blind injustice of such statistical regulations.

What part of that fails to register with you?

Even if it were perfect, the government will figure out how to screw it up eventually.

What gets read one way, will be read another when some pol needs a certain beauracracy to produce certain results....regardless.

 

[dblack]

Still don't see anything in there about them actually determining if a discharge was advisable for medical or personal reason, all they care about is not paying for sick people with preexisting conditions to go back into the hospital.

We're just moving past the part where you flat out lied by saying each measure "does not consider anything but the percentage" then? And the bit where you flat out lied about "digging into the language" for that matter?

QW's statement was correct. Once the target percentage is established, (regardless of how the number is arrived at) the discharges resulting in readmissions aren't investigated - they are just counted. All of them contribute to the total that can eventually result in penalties. It doesn't matter if every single discharge a hospital issues is reasonable and justified, resulting readmissions will count toward the penalty. How you can continue to deny this is really amazing in it's sheer determination, if nothing else.