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In the World of Hospital Readmission Rates, There is More than One Story to Tell

September 15, 2016
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I was fascinated to read a blog post earlier this week from the Centers for Medicare & Medicaid Services (CMS) in which federal officials pointed to a nationwide reduction in avoidable hospital readmissions.

The data from CMS showed that all states but one have seen Medicare 30-day readmission rates fall in a five-year span from 2010 to 2015. The one state that did not lower readmission rates was Vermont, as its rate increased slightly from 15.3 percent in 2010 to 15.4 percent in 2015. What’s more, in 43 states, readmission rates fell by more than 5 percent; in 11 states, readmission rates fell by more than 10 percent, according to the CMS data. Overall, readmission rates fell by 8 percent nationally, the federal agency reported.

This information was of particular interest to me because fresh in my mind was the big Kaiser Health News report from August which revealed that the federal government’s penalties on hospitals for failing to lower their rehospitalization rates have hit a new high, as Medicare will withhold approximately $528 million—about $108 million more than last year. And, the government will punish more than half of the nation’s hospitals — a total of 2,597 —for having more patients than expected return within a month. While that is about the same number penalized as last year, the average penalty will increase by a fifth.

The fines for failure to meet CMS’s avoidable readmissions reduction criteria focus on six conditions: heart attack, congestive heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip and knee replacements, and for the first time this year—coronary artery bypass graft surgery—and are based on readmissions between July 2012 through June 2015. The fines, which adjust payments for hospitals with higher than expected 30-day readmission rates for these targeted clinical conditions, will be levied in October.

Although that KHN report did note that since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped, I became curious to how these two reports on the same issue came to somewhat variant conclusions. Regarding the KHN report, a deeper analysis from Healthcare Informatics Editor-in-Chief Mark Hagland came to the only real conclusion one could draw from that data: it’s time for hospitals to realize that performance improvement is no longer an option; rather, it’s a necessity.

As Hagland wrote, “There is simply no longer any place to hide, for hospitals that have been under-performing in terms of core clinical and operational performance. Hospital and health systems leaders are going to need to begin—if they haven’t already done so, which they really should already have been doing—to leverage data and information technology in pursuit of the ‘blessed cycle’ of continuous clinical performance improvement.” Hagland also noted that there were more than 1,400 hospitals that were automatically exempted from readmission reduction program penalties. “Given that there are 3,414 hospitals covered by the readmissions reduction mandate, 2,597 hospitals being penalized this year actually represents fully 76 percent—more than three-quarters of hospitals—seeing pay cuts as a result of readmissions deemed avoidable by CMS officials,” he wrote.

So given all this information in front of us, why was the most recent CMS commentary on hospital readmission rates so positive? In the blog post, Patrick Conway, M.D., principal deputy administrator and chief medical officer, CMS; and Tim Gronniger, deputy chief of staff, CMS, wrote that “The data show that these efforts are working,” referring to the Hospital Readmissions Reduction Program as well as the agency’s Partnership for Patients initiative, which aims to make hospital care safer and improve the quality of care for individuals as they move from one healthcare setting to another.

What Do the Numbers Really Say?

Taking a deeper look into the CMS data on readmission rates, the agency’s readmission rates table shows a state-by-state breakdown of hospital admissions and readmission rates in 2010 versus 2015. In Alaska, for example, in 2010, there were 9,809 hospital admissions for the given conditions in the federal program, with a readmission rate of 14.5 percent. In 2015, Alaska had 9,954 hospital admissions, with a readmission rate of 13.7 percent, resulting in a reduction of 100 readmitted patients—across all hospitals covered in the state, five years later. Is that really reason to celebrate?

Using this one state example, the data reveals a small change in the raw numbers when you boil it down to the actual number of patients being readmitted. Other states have much higher readmission reduction numbers than Alaska of course, but also have more hospitals and more admissions. Thus, it begs the question, Is this data really an indicator of success, especially when some 76 percent of hospitals in the program are seeing pay cuts as a result of too many avoidable readmissions?