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Readmissions Initiative Under the Microscope Again

January 23, 2013
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A recent study from researchers at the Harvard School of Public Health has indicated the potential danger of the Centers for Medicare and Medicaid Services’ (CMS) Federal Readmissions Reduction Program. The study, which appears in the Journal of the American Medical Association, led by Karen Joynt, M.D., M.P.H. and Ashish K. Jha, M.D., M.P.H., found that teaching and safety-net hospitals that serve uninsured and poor patients were more likely face reimbursement cuts as a result of the initiative.

This is not the first time the readmissions initiative has come under scrutiny. In October, I blogged about two additional studies, one from Ottawa in Canada and the other from Loyola University Medical Center in Chicago, also expressed concerns about comparing hospitals through readmission rates. Those two studies look at the how comparing hospitals by readmissions rates may not always be an indicator of its effectiveness. The Harvard study looks into the kinds of hospitals that will be affected by this measure.

As most know, CMS has already begun tying reimbursement to these rates. If a hospital’s readmissions rate is higher than what the CMS had deemed allowable through its own predictive models, the government agency will be able to cut up to one percent of its reimbursement.

Drs. Joynt and Jha, both professors of health policy and management at the Harvard School of Public Health, looked at claims data from 2008 to 2011; they wanted to look at hospitals that care for “medically complex or socioeconomically vulnerable patients, namely large teaching hospitals and safety-net hospitals.”

Of the 3282 hospitals the researchers looked at, 66.7 percent would receive payment cuts, according to their estimates. The number of teaching hospitals that are likely to receive cuts under this initiative was higher than nonteaching hospitals (44 percent to 33 percent). Furthermore, according to the researchers, safety-net hospitals are more likely to be penalized than non-safety hospitals (44 percent to 30 percent). Overall, large hospitals are much more likely to receive cuts than smaller hospitals, the researchers found.

While they do not explain the results, in a letter that appears in The New England Journal of Medicine, Joynt and Jha say the focus on readmissions rates is misguided for three reasons. 1) They say a small portion of 30-day readmissions rates are actually preventable (27 percent exactly they say later) and much of what drives readmissions rates are out of the hospital’s control. 2) There are better policies in achieving better discharge planning and care coordination. 3) By having hospitals focus on readmissions rates, quality-improvement efforts, related to issues like such as patient safety, are being forgone.

Joynt and Jha make a fair point, in my opinion, when they note how various factors that determine a hospital’s 30-day readmissions rates are difficult to change. This includes, they say, “mental illness, poor social support, and poverty,” all of which are “often deeply ingrained.” There are other strong examples of how readmissions rates can be skewed. For instance, they write, that hospitals with a low mortality rate among patients with heart failure have higher readmissiosn rates, likely because “they keep their sickest patients alive, and those patients are subsequently more likely to be readmitted.”

The end result of the readmissions initiative is the hospitals that need the most help may end up getting punished instead.

Have thoughts on the readmissions initiative? Please feel free to respond in the comment section below or on Twitter by following me at @HCI_GPerna