Is it really fair to penalize hospitals for readmissions?

As new Medicare rules kick in, some 2,200 hospitals nationwide are facing financial penalties for high 30-day readmission rates for myocardial infarction, congestive heart failure and pneumonia. Medicare payments will be lowered by as much as 1%.

Investigators at the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research (SSIEBOAR, catchy acronym, don’t you think?) have come up with a plan that is certain to lower readmission rates across the board. Some have said the idea should be patented but the institute is not-for-profit and thus is willing to share.

The solution is quite simple—let the patients die. Yes, death reduces readmission rates for all diseases, not just MI, CHF and pneumonia.

Oh, there may be some resistance and relatives of the patients may complain, but at least Medicare will be satisfied and after all, isn’t that why we became doctors?

Another outcome measure, hospital length of stay is also positively impacted by death. For example, if the average length of stay for a patient with a heart attack is 4 days, a patient who dies on hospital day #2 would lower the hospital’s average. Death also results in fewer resources being utilized, which saves the hospital money for those patients whose reimbursement is based on the DRG.

I confess. I’m not serious, and the idea is not original.

There are many issues. In most cases, as length of stay is ratcheted down, readmission rates will rise. One way to reduce readmissions is to keep patients in the hospital longer. And what about the things the hospitals and doctors can’t control? A recent studyfound that only 63% of Medicaid patients with diabetes, hypertension and hypercholesterolemia actually took their medications regularly.

So what is the solution?

Assessing quality of care in hospitals is a difficult task. People like me have complained about focusing on processes such as the Surgical Care Improvement Project because adherence to process measures does not always correlate with good outcomes. However, processes are much easier to track than outcomes.

The problem with outcome measures is that experts can’t agree on which ones to measure. Even something as seemingly straightforward as death can actually be complex. A 2010 paper in the British Medical Journal on this subject was reviewed in a blog, which pointed out the difficulties with death as a benchmark. This holds true even when death is adjusted for risk.

Readmission rates are also controlled by physicians, not hospitals. Even concurrent review of readmissions by hospital utilization staffs has not been effective in reducing these numbers.

There is another factor. Here’s an anecdote that might help you understand the problem. An elderly woman was admitted for congestive heart failure. After a few days of intense medical care, she was discharged. She was readmitted for CHF three days later. When interviewed during her history and physical exam, she admitted that she 1) did not take any of her prescribed medications at home, 2) continued to smoke cigarettes and 3) did not follow her cardiac diet.

Is it really fair to penalize hospitals for readmissions, many of which cannot be prevented?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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