Hospital Readmissions Reduction Program & rising deaths: Why are policies that profoundly influence patient care not rigorously studied before widespread rollout?

Did This Health Care Policy Do Harm? Rishi K. Wadhera, Karen E. Joynt Maddox and Robert W. Yeh. The New York Times, Dec 21 2018. https://www.nytimes.com/2018/12/21/opinion/did-this-health-care-policy-do-harm.html

A well-intentioned program created by the Affordable Care Act may have led to patient deaths.


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         The authors are cardiologists and health policy researchers.
No patient leaves the hospital hoping to return soon. But a decade ago, one in five Medicare patients who were hospitalized for common conditions ended up back in the hospital within 30 days. Because roughly half of those cases were thought to be preventable, reducing hospital readmissions was seen by policymakers as a rare opportunity to improve the quality of care while reducing costs.

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.

In a new study [https://jamanetwork.com/journals/jama/fullarticle/2719307] of approximately eight million Medicare patients hospitalized between 2005 and 2015 that we conducted with other colleagues, we found that  the Hospital Readmissions Reduction Program was associated with an increase in deaths within 30 days of discharge among patients hospitalized for heart failure or pneumonia, though not for a heart attack.

The study [...] found that although post-discharge deaths for patients with heart failure were increasing in the years before the program, the trend accelerated after the program was established. Death rates following a pneumonia hospitalization were stable before the Hospital Readmissions Reduction Program, but increased after the program began.

For both conditions, the increase in deaths after the program were concentrated in those patients who had not been readmitted to the hospital after discharge. If we assume that the program was directly responsible for these increases in mortality and that prior trends would have continued unabated, the program may have resulted in 10,000 more deaths among patients with heart failure and pneumonia.

Our findings build upon a smaller-scale study by independent research groups that has also shown that the program was associated with an increase in post-discharge death [...].

How might this have happened? Though policymakers assumed that reductions in readmissions under the program were solely due to improvements in quality of care, our findings suggest otherwise. It is possible that some hospitals treated patients in the emergency room or in an observation unit when they would have benefited most from an inpatient readmission. It is also possible that shifting clinicians’ focus to readmissions distracted them from working to reduce mortality, since the readmissions penalties are over 10 times higher than the financial penalties for high death rates.

We don’t know exactly why we see the patterns we do. And another recent study reported that although deaths after discharge were increasing for heart failure and pneumonia, they did not accelerate under the program. They argue that other changes could have been responsible for the trend, such as an increase in the medical complexity of patients who were admitted to the hospital.

While the problem is complex, the short-term answer is simple — err on the side of caution. Further expansion of the program, from six conditions to all conditions warranting hospitalization, as some policymakers have advocated, makes little sense given legitimate concerns our study and others raise about its repercussions.

In the long term, the Centers for Medicare and Medicaid Services should conduct an investigation into the patterns we and others report. All possibilities should be considered, from coding changes to inappropriately turning patients away from the emergency room to changes in risk factors among Medicare patients. The agency must also engage physicians and patients to understand how this program has influenced “on the ground” care.

More broadly, this continuing debate about the Hospital Readmissions Reduction Program highlights a bigger issue: Why are policies that profoundly influence patient care not rigorously studied before widespread rollout?

[...]

Rishi K. Wadhera is a cardiology fellow at Harvard Medical School. Karen E. Joynt Maddox is a cardiologist at the Washington University School of Medicine in St. Louis. Robert W. Yeh is a cardiologist and director of the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center.
A version of this article appears in print on Dec. 22, 2018, on Page A23 of the New York edition with the headline: A Harmful Health Care Policy?.