Five months before Medicare's hospital readmission penalties take effect, two groups of authors say Congress and the government are taking the wrong approach.
Although the authors make different points, each says that the regulation, embedded in the Affordable Care Act, won't accomplish its intent. Both are published in Perspectives in Thursday's New England Journal of Medicine.
"Policymakers' emphasis on 30-day readmissions is misguided for three reasons," says one article "Thirty-Day Readmissions—Truth or Consequences," by Karen Joynt, MD, and Ashish Jha, MD, of the Harvard School of Public Health.
- Preventability. Only a small portion of readmissions up to 30 days after discharge are preventable, patient and community factors—like poor mental health or poor social support and poverty—drive much of what impacts readmissions and high rates of readmissions may in fact mean better quality of care.
- There are better policies to effect lower readmissions.
- Hospitals may spend energy on reducing readmissions at the expense of efforts to improve patient safety and other quality improvement projects.
Finally, Joynt and Jha wrote, very few of the millions of readmissions being targeted are actually preventable, ranging from at best 59%, but more realistically 12% when clinical data was obtained.
The bottom line, they said, is that "readmissions may be a poor marker of hospital performance."
The second article, by Robert Berenson, MD, of the Urban Institute; Ronald Paulus, MD, of the Mission Health System, Asheville; and Noah Kalman of Duke University in Durham, makes a business case against the penalty.
In their article, "Medicare's Readmissions-Reduction Program—A Positive Alternative," the authors suggest that hospitals, notwithstanding financial penalties for hosp excessive readmissions, "have no economic incentive" under the DRG approach to change unless they are at full capacity. They give two reasons.
- They say the penalty "may be too weak to overcome the substantial counterincentives inherent in the DRG-based payments," which still pay hospitals in the fee-for-service system to care for readmitted patients. The actual reduction in spending avoided by the fines is only .2% of anticipated Medicare payments for 2013, because for most hospitals with average or better readmission rates, payment won't change
- They contend that he direct costs of a readmission prevention program—estimated to average $100 to $200 per discharge—may decrease hospitalizations for other diagnoses not targeted by the readmissions prevention rule.
"If a penalty is more than offset by program costs and lost rehospitalization revenue, hospitals would be better off financially if they maintained the status quo," they wrote.
The authors propose a Medicare pricing system such as Geisinger Health's ProvenCare, which creates a single episode price for all care associated with surgery for 90 days, including any rehospitalizations, "in essence, a warranty."
This would remove entirely "the perverse incentives associated with payments for avoidable readmissions," and Medicare would be guaranteed savings.
They concluded that "increasing penalties for readmissions, but not all admissions, provides a clearer incentive for hospitals to pursue readmissions-reduction programs and enhance quality and efficiency while more fundamental payment reform is being explored."
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