This week, the Journal of the American Medical Association devoted much of its issue to the topic of hospital readmissions. The themed focus reflects both the clinical and administrative importance of understanding the mechanisms that trigger readmissions.
Initiation of the federal Hospital Readmissions Reduction Program, which penalizes hospitals for higher-than-expected 30-day readmissions for heart failure, acute MI and pneumonia, has raised concerns about the consequences of the program. As Cardiovascular Business previously reported, the reason for a readmission is not always related to the index hospitalization. Heart failure, in particular, is a challenging condition that may prove difficult to monitor outside the hospital.
This week, Kumar Dharmarajan, MD, MBA, of Yale School of Medicine in New Haven, Conn., and colleagues reported that demographics or time of readmission had little to do with the readmission. Their finding that most readmission diagnoses differed from the diagnosis on index admission is consistent with other studies. Their drill down into the details showed that cardiovascular disease often spurred the readmission: for heart failure, it was the reason in 52.8 percent of the cases (35.2 percent attributed to heart failure itself) and for acute MI, 53.4 percent (19.3 percent attributed to heart failure).
In a research letter, Karen E. Joynt, MD, MPH, and Ashish K. Jha, MD, MPH, both of Brigham and Women’s Hospital in Boston, looked at the other side of the coin: which types of hospitals likely will face the 1 percent cut in Medicare reimbursement that will be imposed on what are deemed to be poorly performing hospitals. They determined that large hospitals, teaching hospitals and safety-net hospitals are more at risk of penalties than small hospitals, nonteaching hospitals and hospitals that are not considered safety net.
Those hospitals that appear to be in the bull’s eye serve more medically complex and socioeconomically vulnerable patients, that is, they are sicker, poorer and generally more disadvantaged. It is possible these are more challenging patients whose care is made that much more challenging in the presence of cardiovascular disease, especially heart failure.
Sometimes a readmission is precisely the best care for a patient. There are concerns that the penalty initiative may not be able to discriminate some of those cases, unfairly punishing those hospitals. It may prove to not only be unfair but also detrimental to patients who rely on hospitals that, due to penalties, now have dwindling resources. Perhaps even worse, it may give hospitals a disincentive to readmit patients who need to be back in the hospital.
The Hospital Readmissions Reduction Program was designed to reduce burgeoning healthcare costs. But at what price?
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Cardiovascular Business, editor