Tweaking the Centers for Medicare & Medicaid Services' new policy penalizing hospitals for excessive readmissions can avoid unfairly punishing hospitals for factors outside their control, two Harvard research physicians argue in a commentary published Wednesday in the New England Journal of Medicine.
In their article, Karen E. Joynt and Ashish K. Jha note that two-thirds of U.S. hospitals will receive penalties--far more than had been expected--and that safety-net and large teaching hospitals disproportionately care for patients with complex medical problems.
"Left unchecked, the HRRP [Hospital Readmissions Reduction Program] has the potential to exacerbate disparities in care and create disincentives to providing care for patients who are particularly ill or who have complex health needs, particularly if the penalties are larger than hospitals' margins for caring for these patients," they write.
The commentary includes several suggestions to account for those disparities:
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Adjust readmission rates for socioeconomic status by, for example, adding patients' eligibility for Supplemental Security Income to risk-adjustment models. Such an adjustment would show whether safety-net hospitals are achieving readmission rates for poor patients comparable to non-safety-net facilities, they say.
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Weight penalties according to the timing of readmissions, counting readmissions within a few days more heavily than those occurring four weeks later, which are more likely to be attributable to disease severity than lack of care coordination.
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Give hospitals credit for low mortality rates, since they often have higher readmission rates despite being high-performing facilities. Hospitals with high mortality rates but low readmission rates do better under the CMS payment scheme than low-mortality hospitals with high admission rates, the authors note. They suggest CMS could combine the two outcomes by assessing patients' 30-day "days alive and out of hospital."
"Simple changes to the program could ensure that incentives were provided to hospitals to improve coordination of care without hurting the institutions that care for the most vulnerable patients," the commentary concludes.
Another article, published online recently in Population Health Management, looked at three statewide readmission-prevention programs to identify successes and failures.
They identified three obstacles: challenges in developing collaborations across care settings, gaps in evidence of effective interventions, and limited quality-improvement capabilities in some organizations. The findings "suggest that immediate improvement in readmission rates through a change in reimbursement may be unlikely unless these other obstacles are addressed expeditiously," the authors write.
Productive collaboration, in particular, is crucial because the relationships are not common or "naturally occurring," the article notes.
Meanwhile, Medicare Director Jonathan Blum says the readmission reduction program already has produced results. The rate of 30-day readmissions dropped to 17.8 percent in the fourth quarter of 2012, down from between 18.5 percent and 19.5 percent during the past five years, he told the Senate Finance Committee last week.
To learn more:
- here's the NEJM commentary
- read the Population Health Management article