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September 30, 2014 01:00 AM

Systems serving low-income patients struggle under readmissions penalties

Sabriya Rice
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    Hospitals with limited resources continue to struggle as they try to implement programs that drive down readmission rates, and federal penalties could potentially make matters worse, write the authors of a report published in the Joint Commission's Journal on Quality and Patient Safety.

    Socio-economic factors such as homelessness and lack of transportation were commonly cited in interviews the researchers conducted with executives and frontline staff at eight U.S. safety net hospitals.

    In a recent blog post, one of the study authors said he has changed his mind about whether adjustments for socio-economic factors should be considered in the federal hospital readmissions reductions program. “I used to be against it,” Dr. Ashish Jha, director of the Harvard Global Health Institute, wrote in a Sept. 29 blog post. “But having spent more time thinking about it, it's the right thing to do under specific circumstances,” he said.

    The Hospital Readmission Reduction Program, created as part of the Patient Protection and Affordable Care Act, began penalizing hospitals for having excess numbers of patients return to the hospital following treatment for heart attacks, heart failure and pneumonia in fiscal 2013. Hospitals with excess readmissions initially had their Medicare payments docked up to 2%, and the maximum penalty rises to 3% in fiscal 2015.

    In an analysis published in the October issue of the Journal on Quality and Patient Safety, Jha and colleagues interviewed hospital C-suite leaders, as well as chief medical officers, financial and quality personnel, from eight safety net hospitals and detailed their challenges. Four trends were consistent among the hospitals:

    Although readmissions were a called high priority, few could cite actual readmission rates.

    Penalty concerns encouraged hospitals to address the issue, but many still felt they could have little impact on factors outside of a hospital that lead to readmissions.

    Many began with making improvements to the patient-discharge process and building community support for transitional care.

    Most felt they had limited resources to address “idiosyncratic patient needs” and “misaligned incentives."

    “These hospitals are struggling even at their current level of resources to implement programs,” the authors concluded. Readmissions penalties could exacerbate existing disparities as already under-resourced hospitals face further reductions in their financial resources, they said.

    The need to adjust for socio-economic factors in 30-day readmission-rate penalties has received increasing support. In June, a group of U.S. senators introduced the Hospital Readmission Accuracy and Accountability Act, which would require the CMS to account for patient socio-economic status when calculating risk-adjusted readmissions penalties. In July, the National Quality Forum said it plans to do a trial examining the effects of socio-economic factors on hospitals, and the trial may include 30-day readmission measures.

    And a study in the August issue of the journal Health Affairs concluded that a readmission is a good thing in some cases. That study, which compared readmission rates among California hospitals, found safety net hospitals in the state often had better outcomes on 30-day mortality measures, but were more likely to face readmission penalties.

    In his blog post, Jha provides the example of a 64-year old homeless Veteran with diabetes who recently returned the within 10 days despite the hospital doing “everything short of finding [him] and apartment.”

    The issue is nuanced and should be reevaluated, he wrote. “Adjusting for socioeconomic status is an acknowledgement that medicine is not the only factor—and indeed may be a relatively minor factor—in health outcomes."

    Not all 30-day readmissions indicate problems, study says

    Safety net hospitals face socio-economic disadvantages

    Using big data to target preventable readmissions

    Congressional measure may ease concerns over readmission penalties

    Related Content

    Not all 30-day readmissions indicate problems, study says

    Safety net hospitals face socio-economic disadvantages

    Using big data to target preventable readmissions

    Congressional measure may ease concerns over readmission penalties

    Follow Sabriya Rice on Twitter: @sabriyarice

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