Heart failure, which is the most common Medicare readmission, is an incredibly complex condition to treat. And for advanced heart failure patients, a readmission is sometimes unavoidable, said Jay Cyr, senior vice president of surgical services at UMass Memorial Medical Center in Worcester.
"These people are very sick—keeping them out of the hospital is a challenge, and sometimes we can't do that despite our best efforts," he said.
Given the challenges of caring for heart failure patients, it's plausible that tactics hospitals adopt to avoid readmissions have a negative impact on patients' survival rates, said Jason Hockenberry, an associate professor of health policy and management at Emory University who has studied the CMS readmissions program.
Hospitals "change care processes, and they change how they handle patients, which could lead to some fraction of the patient population having their life shortened," Hockenberry said.
That's not to say hospitals turn patients away if they need care, Hockenberry said. But interventions made to help patients avoid a readmission might influence whether or not they decide to return to the hospital or wait to get an appointment with their specialist. Low health literacy among patients might lead to difficulty both in understanding discharge instructions and compliance with subsequent self-care protocols, he said.
"We still don't understand what these incentives are doing to care processes, and how they might be impacting patients," he said. "Are they satisfied with their care? That is unclear at this point."
The CMS also adopted the program across all acute-care hospitals without much insight or evidence into how it will impact hospitals. "We have no idea whether reducing readmissions is going to have an impact on health outcomes," Hockenberry said.
Dr. Karen Joynt, an assistant professor of medicine at Washington University School of Medicine, rejected the notion that the CMS program might be having a negative impact on patient care. "It doesn't kill people to try to improve the discharge process," she said.
Even with the positive statistical results the program has shown in driving down readmissions, Johns Hopkins' Pronovost said the JAMA study warrants more follow-up in terms of the broader impact on outcomes.
"There was a lot of good by increasing attention on care coordination and thinking about patients when they leave the hospital," he said. "But now we have a signal that there are unintended consequences, so I think (policymakers and researchers) really need to come together and talk about why this might be happening and what should we be doing going forward with this measure."
Correction: An earlier version of this story misnamed the Hospital Readmissions Reduction Program. This error has been corrected.