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Pushing Hospitals To Reduce Readmissions Hasn't Increased Deaths

The goal was to make sure hospitals didn't send patients home too soon, without a plan for following up or without enough support at home to recover completely.
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The goal was to make sure hospitals didn't send patients home too soon, without a plan for following up or without enough support at home to recover completely.

Too often, people return home from the hospital only to find themselves heading back soon after. Sometimes the need arises because, despite the best care, it is difficult to slow the progression of disease. But other times, it's because we in the health care system fail to communicate, coordinate and orchestrate the care that people need to successfully make the transition from hospital to home.

Historically, U.S. hospitals have had little incentive to keep patients healthy following discharge. Hospital discharge indicated success, and we paid little mind to what happened on the other side. Meanwhile, 1 in 5 patients returned to the hospital within 30 days of discharge, and the health system largely felt it had no responsibility for that. Hospitals were paid each time a patient was readmitted.

Over time, it became clear that the risk for readmission could be reduced with improved quality of care. For this to happen, hospitals would have to institute programs that would take into account the challenges of managing the recovery period. They would also have to be sure people were strong enough to leave the hospital – and had the support they needed after discharge. And mistakes that were all too common, like sending people home with the wrong medication list, would need to be addressed.

The Affordable Care Act sought to make all of that happen by changing hospital incentives. Hospitals with higher than average readmission rates would be penalized financially. These penalties began in 2012 and have increased over time.

With these new incentives in place, and some investments by Medicare to help places with the highest readmission rates, hospitals across the country have focused on improving care for patients as they transitioned from the hospital to home. More attention was placed on ensuring the inpatient and outpatient medication lists matched. Hospitals found ways to integrate caregivers and family members in the discharge planning. They scheduled follow-up visits after discharge and improved communication between the hospital and outpatient teams.

With these changes, readmission rates dropped dramatically across the nation. Rates declined almost 20 percent for patients hospitalized with heart attacks, heart failure and pneumonia, the conditions included in the Affordable Care Act. Readmission rates also declined for many other conditions not specifically targeted in this part of the Affordable Care Act, though to a lesser degree. In total, hundreds of thousands of patients avoided a return to the hospital.

The drop in readmissions was so significant, it led some researchers and advocacy groups to worry about unintended consequences. Might hospitals, wary of financial penalties, choose not to readmit patients who need inpatient care? Could keeping people out of hospitals lead to more deaths?

We examined those possibilities in a study published Tuesday in JAMA, the Journal of the American Medical Association, and found the answer is no.

After studying more than 6 million hospitalizations from over 5,000 hospitals over a seven-year period, we found no evidence that the reduction in hospital readmissions resulted in greater risk of dying for patients recently discharged.

In fact, hospitals that reduced readmissions the most were, if anything, more likely to reduce mortality after hospitalization. These findings held even for patients with heart failure, who had rising mortality over time as the least sick patients were increasingly treated as outpatients.

How did this happen? To lower readmissions, hospitals needed to better prepare patients and families for discharge and improve the integration and coordination of care from hospital to home. These interventions likely also reduced the risk of death.

Amid the noise of the health care debate, it is useful to reflect on a success such as this. (These incentives would not be affected by the repeal measures under consideration in Congress.)

These better outcomes came about not from new medicines or devices, but from a willingness of hospitals and health care professionals to engage with patients and families to promote truly patient-centered, high-quality care. The idea was to stop focusing on the venue of care and instead recognize the journeys patients are on, and also to stop paying for bad outcomes and instead reward improvements in care. Finally, there was a need recognize that we in health care were not doing as well as we could.

Still, we have more work to do to further reduce readmissions. Our study and others have shown that declines in readmissions have slowed in recent years. Current penalties are determined using data for just six conditions — heart attacks, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery bypass graft surgery and hip/knee replacement surgery. Recalculating penalties to include hospital-wide readmission rates could motivate hospitals to take increased accountability for all of their patients after discharge.

This is doable. A validated measure of hospital-wide readmission rates already exists. And hospitals' performance on this measure is already reported on the Medicare website. The remaining step would be to link reimbursement to these results. And that will require both political will and the willingness of hospitals to take on additional responsibilities for many more of their patients.

Beyond this, we could encourage teamwork among the nation's health systems by minimizing or even halting the use of penalties if patient outcomes improve nationwide. Rather than have winners and losers, all hospitals should benefit if the quality of care for patients increases across the country. Moreover, continued improvements would save the health system many millions of dollars in averted hospitalizations.

In studying hospitals' efforts to lower readmissions, we are reminded that improvements in patient outcomes will often need new ways of thinking, new collaborations and new responsibilities for health care providers. The greatest achievements will almost certainly require that barriers among providers and care settings break down in favor of shared visions and accountability. To get there, incentives and actions need to be aligned to put patients first.

Kumar Dharmarajan is a cardiologist and geriatrician. He is the chief scientific officer at Clover Health, a Medicare Advantage company.

Harlan Krumholz is a cardiologist and the Harold H. Hines Jr. Professor of Medicine at Yale School of Medicine. He directs the Yale-New Haven Hospital Center for Outcomes Research and Evaluation that developed the readmission measures for the Centers for Medicare and Medicaid Services.

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Kumar Dharmarajan
Harlan M. Krumholz