Medicare readmissions drop for 3 high-profile conditions

CMS cites success in a program that fines hospitals $280 million for failing to prevent heart attack, heart failure and pneumonia patients from returning.

By Charles Fiegl amednews staff — Posted March 15, 2013

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Fewer Medicare patients have been returning to the hospital in the months after the Centers for Medicare & Medicaid Services began penalizing facilities for excessive readmissions, a top CMS official said.

The positive signs from the hospital readmissions reduction program drew praise from lawmakers during a recent Senate Finance Committee hearing. The penalties have gone forward despite warnings from hospitals and researchers about the potential harmful effects of the readmissions policy.

The program began cutting pay to more than 2,200 hospitals beginning Oct. 1, 2012 — reductions that were projected to hit $280 million in the first year. CMS is basing those cuts on hospitals’ rates of repeat hospitalizations of Medicare beneficiaries within 30 days of the patients’ initial admissions for heart attack, heart failure and pneumonia. The policy probably will be expanded in the future.

During the final quarter of 2012, CMS saw the all-cause readmission rate fall to 17.8%, said CMS Center for Medicare Director Jonathan Blum, who also is the agency’s acting principal deputy administrator. The rate had been between 18.5% and 19.5% over the past five years.

“This decrease is an early sign that our payment and delivery reforms are having an impact,” Blum stated in Feb. 28 testimony to the committee. Although the program is in its infancy, hospitals had prepared for the penalties for years, he added.

At the same time, new evidence regarding readmissions should cause health policymakers to change the program further, stated Karen Joynt, MD, MPH, and Ashish Jha, MD, MPH, from Harvard University School of Public Health in a perspective published online March 6 in The New England Journal of Medicine.

The Medicare Payment Advisory Commission had suggested that a slight decrease in national readmission rates from 2009-11 was tied to increased utilization by hospitals of observation services, which do not require patients to be admitted to the hospital.

In addition, hospitals that are being penalized are more likely to be considered teaching hospitals or safety net facilities, the Harvard article stated.

“Given these two new insights, we believe that there are several steps that could be taken to sustain the gains that have been achieved while avoiding substantial harm to hospitals that care for the most socially and clinically vulnerable patients,” Drs. Joynt and Jha wrote (link).

Other readmission factors

The researchers recommended that readmission rates account for socioeconomic factors, so hospitals caring for a disproportionate share of poorer and often sicker patients are not penalized unfairly. This is a change the American Hospital Assn. and other organizations have recommended.

Timing of a readmission also should be considered so those occurring hours or days after discharge, for instance, are weighted more heavily than those occurring toward the end of the 30-day period. Finally, mortality rates should be considered, so high-performing hospitals get credit for keeping sicker patients alive, the researchers stated.

“Factoring a hospital’s mortality rate into its readmission-penalty calculation could ensure that the best institutions (those with the lowest mortality rates — often large teaching hospitals) were not inappropriately penalized,” the authors wrote. “As things stand, hospitals with high mortality rates but low readmission rates do better under the CMS payment scheme than hospitals with low mortality rates but high readmission rates.”

The American Medical Association has outlined five responsibilities physicians should consider when caring for patients recently discharged from the hospital (link). The recommendations in the AMA Center for Patient Safety report are: assessment of patient health, goal setting to establish desired outcomes, support for self-management, medication management and care coordination.

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