Low-Income Patient Hospitals and the Readmission Penalties

Regular readers recognize the antipathy we have toward the Medicare hospital readmission penalty program, due to poor design, not the intent.  One of the widely-shared criticisms of the program is its disproportionate impact on hospitals treating lower-income and disadvantaged patients.  (HA Article)  (HA Article)   Two articles in Health Affairs report on research looking at those impacts.  The first  focuses on socioeconomic status and readmissions in a single hospital, using data on thirty-day readmissions for Medicare beneficiaries and demographic and other data on the readmitted patients.  Over 4600 admissions were studied, with around 950 readmissions.  Patients who were male, African-American and unmarried were more likely to be readmitted, and the unmarried status itself may be suggestive of a less extensive support system at the patient’s home.  People living in neighborhoods with lower levels of education and lower income were more likely to have readmissions.  Patients with readmissions also tended to have multiple comorbidities.  Patients living in high-poverty areas were 24% more likely to be readmitted.   The results suggest that hospitals seeing a larger percentage of these patients could be unfairly penalized.  The second study looked at admissions of Medicare patients in Missouri with the three diagnoses currently included in the Medicare program to see if adding socioeconomic data which improve prediction of readmission.  The socioeconomic data was arrived at by looking at the census tract where the patient lives.  On an unadjusted basis, readmission rates were 16.2% for heart attacks, 19.3% for heart failure and 15% for pneumonia, with significant variability across hospitals.  Adding the socioeconomic data reduced variability, dropping hospitals with high rates toward the mean and raising those with low rates.  This strongly suggests that socioeconomic factors affect readmission rates.  A logical and better next step would be to have hospitals gather socioeconomic data on Medicare patients admitted to the hospital, including information about the support system available to the patient.  This data could then be used to conduct more precise analyses of the links between various pieces of socioeconomic information and readmission risk, which would support programs to target higher-risk patients for more post-discharge interventions.