Medicare readmission penalties create quality metrics stress

Medicare is four years into its drive to cut the number of patients who land back in the hospital within a few weeks of leaving, and only a quarter of more than 3,400 hospitals avoided penalties. The results are contributing to skepticism about the readmissions program and the broader array of metrics used to evaluate healthcare quality.

“How's that readmission penalty thing working out for Medicare?” asked Dr. Aaron Carroll, a health policy researcher and editor-in-chief for the Incidental Economist, a critical health policy blog. “Everyone sucks,” he said in a post citing concerns with the program.

The CMS has touted research suggesting the all-cause readmissions rate declined in 2012 and 2013, reaching 17.5% after holding steady at 19% for the previous five years.

But with as much as 6% of a hospital's base operating pay from Medicare expected to be on the line by 2017, health policy and quality and safety researchers, as well as organizations representing hospitals, are urging more scrutiny of metrics used in the government's quality incentive programs.

“The whole field is a mess—it's all over the place,” said Dr. Robert Wachter, interim chair of the department of medicine at the University of California, San Francisco. “We need better science.”

The government has failed to set thresholds for how reliable a measure must be before it's used in a pay-for-performance program, said Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.

“Someone could come up with any new measure and say, 'Trust me, it's accurate,' ” he said.

Pronovost said the National Quality Forum, an independent contractor that works with the federal government to evaluate the quality of measures used in federal reporting programs, should also establish thresholds for the validity of the measures it endorses.

NQF President and CEO Dr. Christine Cassel told Modern Healthcare that she shares concerns about whether Medicare is using the best measures. But she also said more metrics are needed, not fewer. “The fact is that healthcare and human health is a complicated business, and measurement is a science that has to encompass all the complexity of that complicated business.” (Cassel discusses the NQF's search for better metrics in this week's Q&A). Cassel said she is optimistic that the science will get better as more clinical data become available from electronic health records.

Others say the government needs to be nimble about dropping measures that are redundant, not properly risk-adjusted or have paradoxical outcomes. The CMS needs “a rapidly iterative mindset where we don't wait a full calendar year to fix things,” said Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University.

In a recent study published in JAMA, Bilimoria found that those hospitals most often penalized by the CMS for not reducing hospital-acquired conditions tended to do well on other measures.

This fall, the Agency for Healthcare Research and Quality plans to publish a final report on preventable errors tracked since the 2010 launch of a public-private collaboration called the Partnership for Patients. That voluntary program has yielded impressive numbers but also has been criticized for lacking scientific rigor.

Noel Eldridge, senior adviser and public health analyst for AHRQ's Center for Quality Improvement and Patient Safety, said the agency targeted adverse events that could be reduced. “We tried to put together a program that had the right goals, and then we'd try to figure out how to measure it afterward,” he said during a July 29 webinar. “We don't have perfect measures, but we have the best ones that exist.”

Meanwhile, Medicare's pay-for-performance programs are not only dampening hospital payments, but also doctors' attitudes. In a recent survey of physicians, half said they think financial penalties tied to quality metrics negatively affect their ability to provide quality care.

In the 2016 inpatient payment rule issued last month, the CMS estimated Medicare will save $420 million next year by reducing base operating DRG payments to 2,666 hospitals to penalize them for excessive readmissions, a $6 million increase from the 2015 penalties.

Although the reimbursement blow to most hospitals next year will be less than 0.5%, the cumulative impact of Medicare's quality programs is piling up. Certain facilities, such as major teaching hospitals, are disproportionately affected, according to a recent article in the journal Health Affairs, co-authored by Federation of American Hospitals CEO Chip Kahn.

But Doris Peter, director of Consumer Reports' Health Ratings Center, said metrics don't have to be perfect to generate improvements. The organization issued a report last week finding that only nine out of more than 3,000 hospitals achieved extremely low rates on five types of hospital-acquired infections. “We're trying to create targets,” she said. “We realize it's not perfect.”