AHA Report on Hospital Readmissions

With the initiation of the hospital readmissions penalty program by CMS, more research is beginning to focus on the topic.   A simplistic picture is often painted of all readmissions being a reflection of bad care.  A new paper from the American Hospital Association explores the issues.   (AHA Report)  The paper begins with a good categorization of readmissions into planned and unplanned and those related to or unrelated to the initial admission.  Obviously it is the category of related, unplanned readmissions that is the focus.  CMS’ program does not distinguish among all the categories, although it does disregard planned readmissions, but in essence assumes that all excess readmissions must be in the related, unplanned category and relies on risk adjustment methods to ensure hospitals are treated fairly.  But, as the paper points out, CMS’ risk adjusters may not capture all the factors which go into a hospital’s readmissions.

The paper also questions how aggressively readmissions should be controlled by pointing out that prior research has suggested that there is an inverse relationship between 30 day mortality rates and readmissions.  Efforts to limit readmissions might lead to higher patient mortality, which certainly is not the desired outcome.  The linkage between excess readmissions and an ultimate outcome like mortality might therefore be questioned, which undercuts at least the quality component to the readmissions penalties.  Other research has also suggested that there may not be a relationship between hospital performance on general quality measures and readmission rates.  If the quality link is nebulous, the sole rationale for the readmissions penalties appears to be cost control, which is in itself a worthy goal, but not if it has the unintended consequence of actually reducing quality.

We have pointed out in another recent post the flaws in CMS’ approach to readmissions, a flaw which is particularly unacceptable when it probably would involve no more effort to actually do a clinical review of readmissions which might be inappropriate and then not pay for those which are found to be the fault of the hospital’s care.  As it is, research suggests that CMS’ approach will likely penalize some hospitals which appear to have an excess rate of readmissions but which have done nothing to cause those apparently excessive rehospitalizations.  While we aren’t always sympathetic to hospitals, given their role in driving up health spending, this is a case where the current CMS program should be stopped and replaced with a more rational one.