“Sometimes the safer thing and the higher quality of care might be to be readmitted,” he said. “But with significant penalties, the incentive is to do the opposite.”
That sentiment was shared by researchers in a study published in the August issue of the journal Health Affairs. The general assumption that readmissions are inherently bad could be part of the issue, explained lead author Edmund Becker, a health policy professor at Emory University.
His study found that when compared to other hospitals, patients treated for acute myocardial infarction, heart failure and pneumonia at California safety net hospitals had lower 30-day risk-adjusted mortality rates, but the hospitals still were more likely to be fined under the readmissions reduction program.
Several recent studies also have noted socio-economics as a potential issue in the fairness of the program.
In an analysis published in the October issue of the Joint Commission's Journal on Quality and Patient Safety, leaders from eight safety net hospitals said readmissions were a high priority. Despite improvements to their patient-discharge processes and community outreach, they felt they could have little impact on off-site factors, and most had limited resources to address “idiosyncratic patient needs.”
In the newest round of CMS readmission penalties, 39 hospitals received the maximum fine of 3%, and of them 12 of had zero fines in the first two years of the program. Nine of the 39 (about 23%) are in Kentucky.
Forty counties in Kentucky are considered to have “persistent poverty,” meaning 20% or more of the residents have fallen below the poverty line over the past three decades, according to the U.S. Census Bureau's American Community Survey.
Seven of the nine hospitals that received the maximum fine were in persistent-poverty counties, and three received the maximum fine for all three years.
“I'm not surprised by that,” said Nancy Galvagni, senior vice president of the Kentucky Hospital Association. She says the association, in collaboration with the Kentucky Association for Healthcare Quality, is working with hospitals in the state to improve readmission rates, and they are gaining ground. But poverty, especially in the eastern Appalachian part of the state, poses hard-to-address challenges.
“When the government is cutting money, it's hard to fund the programs you need,” she said.
A spokesman for Harlan (Ky.) Appalachian Regional Healthcare Hospital said patient compliance post-discharge is a major issue it has been addressing. The hospital also sees higher rates of patients with COPD and heart failure due to greater numbers of smokers and coal miners. “The penalties are a big concern,” the spokesman said. Current CMS readmission penalties affect Medicare reimbursements from Oct. 1, 2014, through Sept. 30, 2015.
Policy leaders hope in the coming years these mounting uncertainties will be addressed.
The CMS has “raised the financial stakes” but continues to resist requests to adjust for socio-economic factors, said Akin Demehin, senior associate director of policy for the American Hospital Association. He said he anticipates the trend of more penalties for safety net hospitals will continue. An adjustment for socio-economic factors would still maintain the incentive for all hospitals to reduce readmissions, he said.
Pronovost agrees, noting that, “What it says to me is you need a better measure. The public and providers deserve better science than we're actually giving them.”
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