Vital Signs Blog

Blog: Location, location, location may impact hospital readmission rates

The socioeconomic status of patients in a given community may explain some of the variation in hospital 30-day readmission rates. But the quality of the facilities where patients go when they are discharged—a factor the CMS isn't measuring—could also play a key role, according to a study published Tuesday in the journal Health Affairs.

Socioeconomic status alone doesn't explain why hospitals in the poorest communities have slightly higher readmission rates, according to the study, whose authors include two policy experts at HHS.

Patients leaving hospitals in low-income communities were much more likely to be readmitted after being discharged to inpatient rehabilitation or long-term-care facilities compared with patients who went home.

While the opposite was true for those discharged from hospitals in wealthier communities, more granular data is needed to determine which facilities are more likely to result in readmission, according to the Health Affairs study.

The findings raise fresh questions about federal policies penalizing high rates of 30-day readmissions.

Medicare began imposing payment cuts for excessive readmissions in October 2012 on the grounds that they reflect poor quality of care and cause unnecessary healthcare costs.

However, with most hospitals facing penalties in fiscal 2016—which could put as much as 6% of a hospital's base operating pay on the line by 2017—health policy and quality and safety researchers, as well as organizations representing hospitals, have urged more scrutiny of the metric.

Studies have suggested that the burden is higher among safety net hospitals, or facilities that predominantly serve low-income areas, uninsured patients and other vulnerable populations.

But the Health Affairs study authors—Steven Sheingold, director of the Division of Health Financing Policy at HHS, HHS economist Rachael Zuckerman and Adele Shartzer, a research associate in the Urban Institute's the Health Policy Center—conclude that safety net hospitals did not have abnormally higher penalties compared with other hospitals, at least in the first few years of the program.

While safety net hospitals were more likely to receive a penalty, few hospitals overall received penalties of more than 1% (out of a total 3%) in fiscal years 2013 and 2014, and the difference in mean penalty for safety net compared with other hospitals was low.

Furthermore, they found that even after demographic factors were considered, such as patient race and income, the odds of a readmission remained 6% to 7% higher at high-DSH hospitals.

“That means approximately 40% of the overall differential cannot be explained by the factors included in these models,” the authors wrote. Still, they said: “Even small penalties arising from multiple quality-based payment policies could have a large cumulative financial impact on these institutions.”

Some experts have urged that the CMS risk-adjust the readmissions measure for socioeconomic factors. In 2014, the National Quality Forum, which evaluates many metrics used in federal health programs, said it would study the roles of sociodemographic factors like income, education, primary language and race, on various quality measures of care delivery, including readmission.

But policy changes are premature until there is more research allowing better comparisons, the authors of the Health Affairs study write: “It is not clear … that a larger redistribution of penalty dollars would be desirable until the factors that contribute to differences in readmissions are better understood.”


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