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Hospital Readmissions, Mortality Incentives Alarmingly Misaligned

Cheryl Clark, for HealthLeaders Media, April 26, 2012

Only a small portion of readmissions within 30 days are truly preventable. Rather, readmissions depend more on community factors outside the hospital's control, they wrote. One study showed that fewer than 20% of readmissions are preventable.

Safety net hospitals have higher rates of readmission and will be penalized more under the readmission penalty rule. "We know that some of the most important drivers of readmissions are mental illness, poor social support, and poverty, which are often deeply ingrained," Joynt and Jha wrote. Thus, "the current scheme to penalize hospitals with high readmission rates is likely to disproportionately affect institutions that care for poor or minority populations or those with a high burden of mental illness."

Rather than reflecting poor quality of care, a readmission may in fact be a life-saving action, providing "good access to hospital care." Referencing research by Eiran Gorodeski, MD and colleagues at the Cleveland Clinic, published in the New England Journal of Medicine, Joynt and Jha wrote, hospitals with low heart failure mortality rates have higher readmission rates, "presumably because they keep their sickest patients alive, and those patients are subsequently more likely to be readmitted."

Too much emphasis on reducing readmissions may be a misdirection of efforts. When resource-poor hospitals expend so much effort reducing readmissions, "they have probably forgone quality-improvement efforts related to more urgent issues, such as patient safety."

"Many of these deaths are preventable, yet we are focusing tremendous resources on preventing rehospitalizations for three conditions that account for approximately 10% of all hospital admissions in the Medicare population," they wrote. "Even if CMS expands its readmission penalties to include more conditions, the policy will fail to address what patients care about most."

Of course, preventing readmissions is a worthy goal and it will save a ton of money, $7.1 billion over 10 years according to the Congressional Budget Office.

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2 comments on "Hospital Readmissions, Mortality Incentives Alarmingly Misaligned"


Carl (4/30/2012 at 10:59 AM)
It makes sense from a financial point of view. If the patient dies, their expenses cease. It is the money with which CMS is concerned. I have noted in my research that the hospitals with the lowest mortality rates also have higher readmission rates.

Michael Barber MD (4/26/2012 at 3:26 PM)
There is significant data and experience that would indicate that reducing readmissions is a good way to reduce 30 day mortality plus it is easier to measure and does not require risk adjustment like mortality. The problem that hospitals, even high quality ones like Beth Israel, see readmissions as the only way to reduce mortality instead of increasing the community based resources that can increase adherence to therapy and solve many of the non clinical problems that contribute to both readmissions as well as premature mortality. Studies of "hospital at home" for congestive heart failure show that treatment costs are 20% less and complication rates nearly zero as well as fewer clinical relapses. Other studies show that primary admissions for these disesases can be reduced up to 50% by taking a highly integrated person centered approach to our most vulnerable elders. In my mind, the financial incentives to use inpatient resources to heal our patients have caused hospital leaders to have blinders on the work that can be done at the community level.