No Downside to Medicare Penalties for Hospital Readmissions for HF, Acute MI
Measures enacted by the 2010 Affordable Care Act have indeed led to fewer repeat visits but no spike in discharge mortality.
Faced with the prospect of financial penalties for higher than expected readmission rates, hospitals appear to have instituted changes in order to keep patients from returning to hospital. But according to researchers of a new study, changes likely prompted by the 2010 passage of the Affordable Care Act have not led to an increase in postdischarge mortality for patients with heart failure (HF), acute MI, and pneumonia.
Researchers and advocacy groups have been concerned that policies to curb hospital readmissions might negatively affect patient care. Prior research has looked into the relationship between readmissions and mortality, but those findings were based on cross-sectional studies that yielded varying results like a small inverse relationships and no meaningful correlation, Kumar Dharmarajan, MD MBA (Clover Health, Jersey City, NJ) and his colleagues report.
“No studies have examined data longitudinally, which may provide further insights into paired readmission and mortality trends for individual hospitals,” they write. “This information is vital to understanding whether one of the most consequential payment changes affecting hospitals in recent years caused unintended harm to patients.”
The new investigation, published online today in the Journal of the American Medical Association, looks into whether or not hospitals have tried to decrease readmissions rates through methods that might be harmful to patients.
Medical Professionals Are Getting It Right the First Time
From 2008 to 2014, Dharmarajan and his co-investigators assessed over 5 million Medicare patient cases related to HF, acute MI, and pneumonia.
Mean hospital 30-day risk-adjusted readmission rates (RARRs) after discharge declined steadily across all three conditions over the study period at a rate of 0.03 to 0.05% per month. Monthly aggregate changes across hospitals in 30-day risk-adjusted mortality rates, by contrast, remained relatively static, increasing marginally for heart failure (0.008% per month), declining marginally for acute MI (-0.003% per month), and holding steady for pneumonia (0.001% per month).
Dharmarajan and his colleagues conclude: “Reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings did not support increasing postdischarge mortality related to reducing hospital readmissions.”
Karen E. Joynt Maddox, MD, MPH (Washington University School of Medicine, St. Louis, MO), who wrote an accompanying editorial, agrees. These approaches “do not inadvertently increase mortality rates, and may even have some positive effects,” she says,
Cardiologists should find these results reassuring, Joynt Maddox explained to TCTMD. In her experience as a researcher, there has not been any “evidence that hospitals were doing anything nefarious or dangerous,” she said. Rather, “most hospitals were working hard to reduce readmissions by doing things like hiring care coordinators or improving their discharge planning or making sure that patients had a follow up appointment on discharge.”
As such, the study offers “even more reason to continue this important work helping patients transition safely from hospital to home,” the editorial notes.
Bringing a Halt to Medical U-Turns
Dharmarajan acknowledged that some people are concerned that readmission reductions might worsen the disparities in care for patients who are socially disadvantaged and from racial or ethnic minority groups in safety net hospitals. Although people often raise the question of whether or not penalizing these hospitals is actually the best option, he said, research indicates “safety net hospitals that largely care for people who are more socially vulnerable” actually show greater declines compared with non-safety-net hospitals when the policies are enacted.
Joynt Maddox would like to see more research being done in the future to better “understand what we can do to actually reduce readmissions further and doing that will require us to think about the outpatient setting and about social determinants of health about how we’re really meeting patients’ needs outside the hospital.”
To TCTMD, Dharmarajan suggested researchers look into what interventions have been most effective in reducing readmissions, so that the medical community “can understand to a greater extent how that has happened,” in order to “be more efficient with the strategies we are using going forward to get the greatest value.”
Dharmarajan K, Wang Y, Lin Z, et al. Association of changing hospital readmission rates with mortality rates after hospital discharge. JAMA. 2017;318:270-278.
Joynt Maddox KE. Readmissions have declined, and mortality has not increased: the importance of evaluating unintended consequences. JAMA. 2017;318:243-244.
- Dharmarajan reports serving as a consultant and scientific advisory board member for Clover Health at the time this research was performed. He has worked under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures.
- Joynt Maddox previously served as a senior advisor at the US Department of Health and Human Services, and she continues intermittent contract-based work with the agency.