Is Medicare being too tough on hospitals with high readmission rates?

Medicare’s Hospital Readmission Reduction Program, mandated by the 2010 Affordable Care Act (ACA) law to reduce the high costs of readmission, is targeting the 20 percent of Medicare patients who return to the hospital within one month of discharge. Those patients cost the government an extra $17.5 billion in 2010.

To date, Medicare has penalized a total of 2,217 hospitals in the first year of the program, which began Oct. 1. Of those, 307 were docked the maximum amount: 1 percent of their regular Medicare reimbursements, according to a Kaiser Health News analysis.

Hospitals, which lose a portion of their Medicare reimbursement when the penalties hit, are understandably unhappy with the new program. And a new meta-study by the Journal of General Internal Medicine suggests that Medicare may not be fully taking into account several important social factors when it makes its readmissions judgments.

A team of researchers reviewed 72 studies for the General Internal Medicine article. One omission they found is that most risk models—which determine who is most likely to be readmitted—do not include social factors. They concentrated on readmissions after heart failure and community-acquired pneumonia over a 30-day period. Here are some factors that were discovered that may have an impact on readmissions:

• Low-income Medicaid (dual eligible) recipient
• Age, gender and race
• Lower education (high school education or less)
• Older age (linked with worse outcomes)
• High-risk behaviors (substance abuse, smoking, ignoring doctors' advice, etc.)
• Lack of social support (living apart from family, living alone, unmarried)
• Housing situation (such as in a rural area)
• Unemployment
• Health literacy and language proficiency
• Neighborhood (proximity to health care, level of community poverty, etc.)

"We don't yet know how to accurately measure (the factors), but I think we found enough information to say that they are important and that they should continue to be studied and accounted for," lead author Dr. Linda Calvillo-King, an assistant professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas, told Reuters Health.

Calvillo-King said she decided to examine the issue when she discovered that some patients at her hospital were readmitted because of "issues like not being able to take their medication or being unable to get to doctors' offices."

Complex Reasons for Readmissions

Since I've personally had some experience with extensive readmissions with family members, I can see why it's often difficult and unfair to attribute the reason for readmission to poor hospital care. Hospitals are often the last place the chronically ill want to go.

Cancer patients, for example, mostly have access to chemotherapy and radiation through clinical settings or outpatient wings of hospitals. But sometimes the cure is worse than the disease, such as when chemo breaks down the immune system and cancer patients have to go to the hospital to battle a serious infection.        

For cancer patients whose immune systems are compromised for any number of reasons, they may need to be admitted just to receive powerful antibiotic therapy or to be isolated in wards to protect them from the "superbugs" that are resistant to most front-line antibiotics. Although not generally a socio-economic factor, this is a huge issue for those with chronic illness that can't be addressed in clinical situations.

Policymakers also need to examine closely the omnipresent relationship between the demographic profiles of those who traditionally get the best—and worst—medical treatment. Poverty is a powerful factor in readmissions.

Is it possible that poorer patients who are facing large co-payments are more reluctant to pursue follow-up care at the clinical level, resulting in later hospitalization? Or perhaps that they lack access to internists, eventually going to the hospital when they become critically ill because they didn't have the kind of clinical care that would have kept them out of the hospital? This has been a persistent pattern in emergency room care.

In this regard, the readmission study follows what researchers already knew: those who are less educated, under- or unemployed, low-income or lacking social support are likely to fare much worse than those patients higher on the socio-economic scale.

This brings up an ethical question that Medicare needs to consider carefully: Are the hospitals likely to receive penalties for high readmission rates also serving the highest-risk and poorest populations? If so, aren't they being penalized for factors beyond their control? Taking that assumption one step further, wouldn't the penalties create disincentives to readmit people who are not getting basic health support services in the first place? That question alone should trigger a deep inquiry into the availability of clinical services in poorer or more rural communities. The Affordable Care Act provides for some expansion of care in these areas, but it will be important to know whether Medicare patients will be adequately served.

If further study shows that an underserved population could be better helped in home or community care settings, that might be a better approach to the readmission problem, rather than penalizing hospitals. This is not to say that some hospitals don’t provide more comprehensive care than others.

Few would argue that affluent communities and urban teaching hospitals may have greater resources and offer better overall care than community or rural institutions. But Medicare needs much more information on the kinds of patients most likely to be readmitted. Where do they live? How much does their education level impact their mode of self-care? Is someone monitoring their medication in a home setting?

The study's authors were optimistic that more of this information would become available through widespread use of electronic medical records "to examine these issues in greater depth with large patient populations, and in a way not possible with administrative billing databases."

While the General Internal Medicine study doesn't reach any hard conclusions, it's clear that a more precise study is needed on socio-economic factors. Ultimately, Medicare may have to hit the streets to target specific groups in community settings in order to achieve lower readmission rates. 

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