Medi­care read­mis­sion penal­ties should take ag­nos­tic ap­proach

Medi­care read­mis­sion penal­ties should be ag­nos­tic to un­der­ly­ing con­di­tions

Modern Healthcare - - NEWS - MER­RILL GOOZNER Ed­i­tor

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New re­search pub­lished last week in a themed is­sue of the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion calls into ques­tion the cur­rent struc­ture of Medi­care’s Hospi­tal Read­mis­sions Re­duc­tion Pro­gram, which pe­nal­izes hos­pi­tals if they have ex­ces­sive 30-day read­mis­sion rates. The op­er­a­tive take­away should be amend, not end.

The lead study found that a large ma­jor­ity of the pa­tients read­mit­ted within 30 days of hos­pi­tal­iza­tion be­tween 2007 and 2009 for heart fail­ure, heart at­tacks and pneu­mo­nia—the three con­di­tions pe­nal­ized un­der the CMS pro­gram—had been re-hos­pi­tal­ized for a dif­fer­ent rea­son.

A quar­ter of Medi­care-el­i­gi­ble heart fail­ure pa­tients re­turned within 30 days, but only a third of them had suf­fered an­other heart fail­ure in­ci­dent. A fifth of heart at­tack vic­tims re­turned within a month, but only 10% of them pre­sented with an­other heart at­tack. And 18% of pneu­mo­nia pa­tients were read­mit­ted, but less than a quar­ter of those were for re­cur­rent pneu­mo­nia.

The report noted that those hospi­tal fre­quent fly­ers, who are a ma­jor driver of ris­ing Medi­care costs, al­most al­ways suf­fer from a num­ber of co­mor­bid con­di­tions that re­quire con­stant at­ten­tion. This isn’t sur­pris­ing given the mean age of those read­mit­ted for all three con­di­tions hov­ered near 80. Add to that the shock and stress of hos­pi­tal­iza­tion—what Yale car­di­ol­o­gist Har­lan Krumholz calls “post-hospi­tal syn­drome” (see “Hospi­tal mak­ing you ill?” Jan. 21, p. 10)—and the chal­lenges fac­ing physi­cians and hospi­tal ad­min­is­tra­tors in re­duc­ing read­mis­sions be­come clearer.

What won’t work is tak­ing a silo ap­proach to treat­ing ei­ther the con­di­tions that led to the ini­tial hos­pi­tal­iza­tion or th­ese pa­tients them­selves. The move to­ward ac­count­able care or­ga­ni­za­tions that co­or­di­nate care from the pri­mary physi­cian to the post-acute-care set­tings is ob­vi­ously a start. But as an­other study in the jour­nal pointed out, en­gag­ing a num­ber of providers that touch th­ese pa­tients in com­mu­nity set­tings—from nurs­ing fa­cil­i­ties to area so­cial ser­vice agen­cies—can have a ma­jor im­pact in low­er­ing ini­tial hos­pi­tal­iza­tion rates, which in turn low­ers the to­tal num­ber of read­mis­sions.

For nearly a decade, health­care qual­ity cru­saders in the pol­icy world, and even­tu­ally the CMS, pushed for pay-for-per­for­mance pro­grams that fo­cused largely on hos­pi­tals’ and physi­cians’ ad­her­ence to a num­ber of clin­i­cal best prac­tices un­der the as­sump­tion that bet­ter per­for­mance would lead to bet­ter out­comes. But as we saw in a re­cent Mod­ern Health­care report (“Qual­ity para­dox,” Jan. 7, p. 6), there is a lim­ited con­nec­tion be­tween suc­cess­ful ad­her­ence to qual­ity met­rics in the CMS’ value-based per­for­mance pro­gram and bet­ter out­comes like read­mis­sions. Ap­par­ently, there isn’t a fixed playbook for how to achieve success.

The lat­est group of stud­ies in JAMA sug­gests the same can be said for re­duc­ing read­mis­sions. The goal is the right one. If the to­tal num­ber of read­mis­sions and the read­mis­sion rate go down, it shows hos­pi­tals are do­ing some­thing right and Medi­care, pa­tients and the tax­pay­ers will save money.

But us­ing a silo ap­proach to pe­nal­iz­ing hos­pi­tals for spe­cific rates of ex­cess read­mis­sions—the pro­gram is set to ex­pand to chronic ob­struc­tive pul­monary disease, coronary artery by­pass graft surgery and per­cu­ta­neous coronary in­ter­ven­tions in 2015 with po­ten­tial penal­ties ris­ing from 1% to 3% of Medi­care re­im­burse­ment—may not be the right ap­proach.

Medi­care should move to a per­for­mance-based stan­dard that pe­nal­izes or re­wards hos­pi­tals for their over­all read­mis­sion rate. Let them fig­ure out how best to achieve that in col­lab­o­ra­tion with lo­cal physi­cians and the lo­cal com­mu­nity.

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