July 22, 2017 Kim Krisberg 0Comment

With the future of the Affordable Care Act still up in the air, most of the news coverage has gone to insurance coverage, premiums and Medicaid. And rightly so. But also included in the massive health reform law were a number of innovative measures to improve the quality and value of the medical care we actually get in the doctor’s office. With repeal still on the table, those measures are at risk too.

One of those ACA efforts is the Hospital Readmissions Reduction Program, which reduces Medicare payments to hospitals with relatively high rates of often-preventable hospital readmissions. The program is focused on readmissions after an initial hospitalization for a select group of conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, elective hip or knee replacement, and coronary artery bypass graft.

The idea is to incentivize hospitals to adopt protocols that improve the quality and coordination of care so that patients can avoid costly and stressful readmissions to the hospital. Luckily, there are a number of protocols shown to work, such as providing patients and caregivers with better discharge instructions, coordinating post-hospital care with a patient’s primary care doctor, and improving efforts to prevent surgical site infections.

So far, research shows such readmission rates have been falling since 2012, when the ACA financial penalties kicked in (though it’s important to note that hospitals began receiving and reviewing their Medicare readmission data back in 2009). Federal officials estimate hundreds of thousands fewer readmissions between 2010 and 2015. Still, every new initiative comes with concerns, as did this one: Would financially penalizing hospitals for readmissions encourage them to deny patients needed care? Does reducing readmissions among Medicare patients increase death rates after discharge?

Kumar Dharmarajan set out to examine that question in a study published this month in JAMA. He and co-authors not only found no increase in death rates; they actually detected a slight decrease in death rates associated with heart attack, heart failure and pneumonia.

“It was an important question because the financial penalties for readmissions have been one of the biggest changes in payment policies in recent years,” Dharmarajan, chief scientific officer at Clover Health, a Medicare Advantage insurer, told me. “Honestly, I wasn’t surprised at the results. Strategies that hospitals take to lower readmissions are generally very patient-centered and they should really be standard patient care. …Plus, the idea that hospitals would keep sick patients out isn’t in the DNA of doctors.”

But it’s still important to look for any unintended consequences of such a big policy change — one that essentially changed a key hospital revenue stream from paying based on quantity to paying based on quality.

To conduct the study, Dharmarajan and colleagues analyzed Medicare data on patients ages 65 and older who were hospitalized for heart failure, heart attack and pneumonia between 2008 and 2014. During that same time period, 30-day readmission rates declined across hospitals for the three conditions. The study found that the decrease in readmission rates for the three health conditions did not coincide with an increase in death among patients. Instead, they actually found a slight decrease in death for the three conditions. To quote the study directly: “Reductions in 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge.” In fact, researchers found an even stronger link between reduced readmissions and reduced mortality at 90 days after initial discharge from the hospital.

Dharmarajan and co-authors Yongfei Wang, Zhenqiu Lin, Sharon-Lise Normand, Joseph Ross, Leora Horwitz, Nihar Desai, Lisa Suter, Elizabeth Drye, Susannah Bernheim and Harlan Krumholz write:

Researchers and policymakers have also expressed concern that penalizing hospitals caring for patients with low socioeconomic status could worsen disparities for this vulnerable group of patients. However, recent national declines in readmission rates have been greater at hospitals caring for patients with low socioeconomic status and have therefore reduced disparities in readmission across hospitals. In this context, this study has shown that hospitals with greater readmission reductions have had greater improvements in mortality. Hospitals nationally have made significant efforts to lower readmissions through improved transitional and postacute care.

“Hospitals really pushed to increase responsibility and accountability for patient outcomes after discharge,” said Dharmarajan, also an adjunct faculty member of Yale School of Medicine. “It’s a win for patients and for the health care system. This policy really did lead to physicians breaking down the siloes that had separated the inpatient and outpatient world.

“And it’s an example of a win that didn’t occur because of an expensive new technology or new drug, but because of very purposeful collaborations between patients, providers, hospitals and providers out in the community,” he said.

Dharmarajan noted that while some hospitals were aware of and even working on their readmission rates before the ACA, the law certainly motivated hospitals to further invest in the kinds of care coordination strategies shown to improve patient outcomes. In other words, the ACA aligned payment incentives in way that put long-term patient health outcomes front and center.

“Initially, I think hospitals were very uncomfortable with the idea of being held accountable for patients after discharge because so much is out of a hospital’s control,” Dharmarajan said. “But there are times that readmission is the result of suboptimal care, like not setting up adequate supports for a patient after discharge. …Now, this idea of reducing readmission is becoming a common part of clinical practice.”

Of course, the future of the Hospital Readmissions Reduction Program, which is overseen by the Centers for Medicare & Medicaid Services, is uncertain if the GOP succeeds at repealing the ACA. It’s yet another example of the significant, often life-saving, health gains made under the ACA that are now at risk.

“Even if the financial penalties were taken away (under an ACA repeal), I’d like to believe the effort would continue because it’s the right thing to do,” Dharmarajan told me. “It would be an interesting national experiment, but I really hope we don’t go there.”

To request a full copy of the new study, visit JAMA.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.

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