As readers know, I have not been a fan of the CMS hospital readmissions penalty program. Now there may be another reason for a closer look at continuing this mis-designed initiative. A study in JAMA Cardiology suggests that lower readmissions may be associated with higher mortality. (JAMA Int. Med.) The authors looked at over 115,000 patients admitted to one of 416 hospitals for heart failure over the period before and after implementation of the CMS readmissions penalty program. The background to the readmissions penalty is well-known; “experts” decided that many hospital readmissions were avoidable and came up with a formula to penalize hospitals for excessive readmissions. A large percent of all hospitals are being penalized by a reduction to their Medicare payments. As with all government interventions, this one can have unintended consequences, as hospitals attempt to find strategies to avoid the penalties. In the case of readmissions this can include changing ER triage criteria to avoid readmitting a patient, delaying admissions beyond the 30 day trigger period and using observations stays instead of admissions; all of which could harm patient care and health.
And that may be what is happening. Risk-adjusted 30-day readmission rates for this large cohort of heart failure patients have indeed declined, from 20% before the program to 18.4% for admissions occurring in 2014 and one-year readmission rates showed a similar trend, going from 57.2% to 56.3%. But at the same time mortality among these patients appears to be rising. 30-day mortality has increased from 7.2% to 8.6% and one-year mortality from 31.3% to 36.3%. Not exactly the increase in quality that the program’s proponents had hoped for. Maybe some of those people who weren’t readmitted in hopes of avoiding a penalty actually needed to be in a hospital.