The case against readmission payment penalties

In JAMA, Karen Joynt, E. John Orav, and Ashish Jha make the case against readmission-based payments:

Despite ongoing interest in understanding disparities, much of the previous work has focused on differential outcomes between racial groups, without taking into account the systems within which care is delivered. Given that care for black patients is concentrated among a small number of hospitals,[5] understanding how outcomes vary as a function of where patients receive care can help policy makers target interventions. We found that the association of readmission rates with the site of care was consistently greater than the association with race, suggesting that racial disparities in readmissions are, at least in part, a systems problem—the hospital at which a patient receives care appears to be at least as important as his/her race.

It is unclear why patients discharged from hospitals that serve a high proportion of black patients had higher odds of readmission. Adjusting for differences in structural characteristics such as teaching status, size, and ownership had little effect on our primary findings. Similarly, adjusting for the proportion of Medicaid patients and hospitals’ Disproportionate Share Index did not explain the differences between hospitals, suggesting that either our measures of financial stress are inadequate or that the higher readmission rates among these hospitals are due to other factors, such as a failure to prioritize quality or inadequate focus on transitions of care and coordination of care. Several studies have found that interventions beginning in the hospital and focusing on transitional care can reduce readmissions,[30-32] but whether minority-serving hospitals engage in such programs as often or as effectively as non–minority-serving hospitals is unclear.

Factors beyond hospitals’ control might explain our findings. Chronic medical illness requires close outpatient management. Early outpatient follow-up after hospitalization[33] as well as disease management and patient education[34-36] can reduce readmissions among both white and minority populations. It may be that availability of high-quality outpatient care is limited for patients discharged from minority-serving hospitals; these issues should be better understood before hospitals are held solely accountable for high readmission rates. […]

It is critical to understand how recently enacted policies, especially those that penalize hospitals with high readmission rates, might impact disparities in care. Our findings suggest that minority-serving hospitals might be disproportionately affected by such penalties.

Related findings by Joynt and Jha appear in this Circulation article. But, back to their JAMA article. I really like their attention to mortality:

First, we censored patients who died between discharge and 30 days of follow-up. Next, we used a composite end point of all cause death or readmission in 30 days as our primary outcome. We also added each patient’s number of admissions for the prior year and in-hospital procedures into the model. […]

Excluding patients who died between discharge and 30 days or considering a composite outcome of death or readmission, as well as adding prior hospitalizations and in-hospital procedures to our model, eliminated the disparities in 1 subgroup: for patients with CHF at non–minority-serving hospitals, there were no racial disparities in readmissions. However, the disparities persisted for patients with CHF at minority-serving hospitals and for patients with acute MI or pneumonia at either type of hospital.

Joynt and Jha also published a NEJM Perspective I’ve referenced but never quoted. It makes some of the points that have come up in my many posts on hospital readmissions, among others.

[O]nly a small proportion of readmissions at 30 days after initial discharge are probably preventable, and much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital’s control. Furthermore, it is unclear whether readmissions always reflect poor quality: high readmission rates can be the result of low mortality rates or good access to hospital care. […]

[W]hereas some studies have shown that sustained efforts can reduce readmission rates somewhat, others have shown that interventions aimed at improving care coordination and access to follow-up care actually increased the rate of readmissions, presumably because of improved access to needed care, with commensurate improvement in patient satisfaction.[5] These interventions should hardly be seen as failures.

All three papers are ungated.


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