Austin has been on a tear discussing readmissions. See this and this and this and this. Along with that, he notes an argument against readmission penalties in Medicare.
I’m following his thoughts with interest. While I share his concern about forcing reduced readmissions for serious issues leading to increased mortality, in general I think we could do a much better job of managing care outside of the hospital to prevent recurrent inpatient stays. But I completely agree that tying reimbursement to performance metrics is sketchy. See this and this and this and this. Most of my issues center around the fact that we often measure what’s easy to measure – not what’s directly linked to patient centered outcomes. We perform to improve the metrics, even if they don’t influence improvements in actual care.
This week’s issue of JAMA was dedicated to this topic. From a Viewpoint entitled, “Tension Between Quality Measurement, Public Quality Reporting, and Pay for Performance“:
Pay-for-performance programs assume that administrative data accurately represent the care provided. This assumption may hold for conditions that are unambiguously definable; however, in many instances, P4P may primarily affect reporting, not outcomes. As payment rates for various codes change, hospitals will favor higher-paying codes and avoid lower-paying or nonpaying codes. Similarly, in response to public reporting, hospitals and physicians will predictably modify their billing data to enhance apparent performance.
Ashish Jha also had a nice piece, “Time to Get Serious About Pay for Performance“. His conclusion:
Pay for performance—putting real money at risk to motivate hospitals to take responsibility for patient outcomes—remains an attractive notion. However, it will only succeed by making bold choices, monitoring its effects closely, and changing the approach when the evidence suggests it is not working. Experimentation with different models that put more dollars at risk for poorly performing hospitals may be one option, using these dollars to focus them on patient outcomes. While some institutions will lose in this new scheme, their patients are already losing now—too many continue to have adverse outcomes in US hospitals because of poor-quality care. P4P represents an enormous opportunity to right the ship, but only if policy makers are willing to be courageous, learn along the way, and remain focused on the primary mission of the health care system: to ensure that patients achieve the best outcomes possible.
I don’t think there’s anything wrong with his assertions. I just remain skeptical that policy makers will do what he recommends. Prove me wrong.
