Reform Update: Broad approach may be better for reducing readmissions, study suggests

As the CMS begins the second year of a penalty program for preventable hospital readmissions required by the healthcare reform law, new research indicates that hospitals fare better when they focus on patient care more generally rather than targeting specific conditions, such heart failure, or specific timeframes, such as 30 days post-discharge.

According to the study, published in the British Medical Journal, top-performing hospitals had fewer readmissions across the board, regardless of condition. Those findings could have significant implications for hospitals that are concentrating their improvement efforts on particular areas, such as heart failure care, the authors said.

“Our findings suggest that hospitals may best achieve low rates of readmission by employing strategies that lower readmission risk globally rather than for specific diagnoses or time periods after hospitalization,” said Dr. Kumar Dharmarajan, a visiting scholar at the Center for Outcomes Research and Evaluation at Yale, and the study's lead author.

Researchers from the Yale University School of Medicine analyzed three years of Medicare data covering more than 600,000 30-day readmissions for heart failure, heart attack or pneumonia at more than 4,000 hospitals.

Those are the same conditions tracked by the federal government's Readmissions Reduction Program, a provision of the Patient Protection and Affordable Care Act that docks hospitals with high rates of readmissions on their Medicare payments. More than 2,200 hospitals will lose up to 2% of their base-operating DRG payments in the upcoming year, up from a 1% maximum penalty in 2013.

The results come as many initiatives targeting smaller subsets of readmissions are seeing lackluster results, the authors said.

Dr. Harlan Krumholz, professor of cardiology at Yale University of Medicine and another of the study's authors, said the study demonstrated the need to focus on the “patient as a whole rather than what caused them to be admitted.”

“And this study adds emphasis to the idea that patients are susceptible to a wide range of conditions after hospitalization—they are a highly vulnerable population and we need to focus intently on making the immediate post-discharge period safer,” he said.

The CMS will raise the readmissions program's maximum penalty to 3% in 2015 and will also add chronic lung disease and elective hip and knee replacement surgeries to the list of measured conditions, according to a final inpatient payment rule released in August.

Researchers from the University of California, Davis, and the University of Rochester have published data disputing the argument of some economists that people are more likely to engage in risky behaviors, such as smoking or going without seat belts, once they obtain health insurance.

According to findings published in the Journal of the American Board of Family Medicine, newly insured consumers are more likely to seek out preventive care, including screenings, but they are not more likely to change health-related behaviors.

“The notion that people with insurance will exhibit riskier behavior is referred to by economists as 'ex ante moral hazard' and has its roots in the early days of the property insurance industry,” said Dr. Anthony Jerant, professor of medicine at UC Davis and the study's lead author. “After buying fire insurance, some people wouldn't manage fire hazards on their property. But healthcare is different. Someone might not care if their insured warehouse burns down, but most people want desperately to avoid illness.”

The study comes as millions of Americans are expected to purchase coverage in the coming months through state-run exchanges and the federal government's glitch-plagued insurance marketplace.

New York-based Montefiore Medical Center was awarded a $1.17 million grant from the New York State Department of Health to develop its Center for Comparative Effectiveness Research. The center, established earlier this year, is a joint project with researchers from the Albert Einstein College of Medicine of Yeshiva University targeting care for underserved populations.

"The diverse patient population we serve in the Bronx has been largely excluded from the clinical and comparative effectiveness research that has essentially determined which drugs to use and how people are treated," said Dr. Julia Arnsten, chief of the division of general internal medicine at Montefiore. "Our center hopes to contribute to the understanding of how therapies impact different groups so as to better direct—and customize—patient care."

The announcement comes as the Patient-Centered Outcomes Research Institute is accelerating its own efforts to bolster comparative effectiveness research. The Washington-based group, established by the healthcare reform law, recently announced its approval of more than $1 billion in grant funding for 2014 and 2015.

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