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Unintended Consequences of Hospital Readmissions Reduction Program

By August 27, 2019Commentary

Hospital readmissions were identified as a potential quality problem.  People came up with potential solutions to the problem, including penalizing hospitals for what were perceived as excessive readmissions.  CMS, which runs the Medicare program, came up with its formula and began implementing it several years ago and a large number of hospitals, 82% in 2019, have seen their Medicare revenue cut as a result.  Nobody likes to lose revenue, so how have the hospitals responded.  Some undoubtedly have improved discharge care and taken other steps to prevent truly avoidable readmissions, but as an article to the British Medical Journal reveals, some other creative approaches have also developed.   (BMJ Article)   The authors looked at total hospital visits by a Medicare FFS patient following an inpatient admission for heart failure, heart attack or pneumonia during the time period from January 1, 2012 to October 1, 2015.  The types of visits included a straight hospital readmission, a treat and discharge visit to the hospital ER and an observation stay not leading to an admission.

Over 3 million admissions were included in the study.  During the study period total revisits to a hospital following an initial admission for a target condition increased by about .023 visits per month per 100 discharges, which over the large number of admissions adds up.  This net increase was composed of a .023 visit per month per 100 discharges increase in ER treat and discharge revisits; a .022 increase in observation stay revisits and a .023 decrease in actual hospital inpatient readmissions.  So while readmissions decreased, the other kinds of revisits more than took up the slack.  Hard not to imagine that this may have been due to hospitals working very hard to ensure that patients with the measured reasons for initial admission were handled on a revisit by use of some avenue other than a readmission. It also leads to the conclusion that the reduction program did not in fact lead to a reduction and may not have saved Medicare any money.  There was no significant change in mortality during the study period so the program and the hospitals’ response to it didn’t seem to either increase or decrease that risk.  Now CMS’ response to research like this might be to just try to include all kinds of revisits in its outcomes measures.  But this program is deeply flawed and I still believe should only be done as an actual examination of the appropriateness of every readmission; that is the only truly fair way to operate a program with such significant penalties.  And once again, evidence of another government program gone awry, but what the heck, let’s just turn the whole health system over to it.

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