Co-written with Thomas Tsai, MD, MPH, Department of Surgery, Brigham and Women’s Hospital
Why readmission penalties are controversial
Penalizing hospitals for high readmission rates has been pretty controversial. Critics of the program have argued that readmissions have little to do with what happens while the patient is in the hospital and are driven primarily by how sick or how poor the patient is. Advocates of the readmissions program increasingly acknowledge that while readmissions may not reflect the quality of care that occurred within the hospital, someone should be accountable for what happens to patients after discharge, and hospitals are the logical choice. While the controversy continues, there is little doubt that the metric is here to stay. This October, the CMS Hospital Readmissions Reduction Program (HRRP) will increase its penalty on excess readmissions from 1% to 2% of total hospital reimbursement.
So far, CMS has focused on readmissions that occur after patients are discharged with one of three medical conditions—acute myocardial infarction, pneumonia, and congestive heart failure. The data on the impact of the program are mixed: while readmission rates appear to be dropping, the penalties seem to be targeted towards hospitals that care for some of the sickest patients (academic medical centers), poorest patients (safety-net hospitals) and for heart failure, some of the best hospitals (those with the lowest mortality rates). No wonder the program has been controversial.
Why surgery may be different
In 2015, CMS extends the program to focus on surgical conditions, which provides an opportunity to think again about what readmissions measure, and what it might take to reduce preventable ones. And if you think about it, surgery may be different. Most patients who are admitted for Acute MI, CHF, and pneumonia are chronically ill and bounce in and out of the hospital, with any one hospitalization likely just an exacerbation of underlying chronic illness (especially true for pneumonia and heart failure). Not so for surgery—at least not for the major surgeries.
Yes, many of these patients have chronic illnesses, but when a patient is admitted for surgery, he or she is relatively stable (except, of course, during emergency surgeries). A hip replacement is not just an exacerbation of osteoarthritis but is meant to cure or alter that disease. Patients should not need to be hospitalized again—at least not right away, if everything goes well. But this is an empirical question – are surgical readmissions picking up something different than medical ones?
In the September 19, 2013 issue of the New England Journal of Medicine, we publish our findings on the relationship between hospital surgical quality and readmission rates. The quality of surgical care is deeply important—the average American undergoes 9 surgical procedures over the course his or her lifetime. We focused on six major surgeries. The ones we chose are common, costly, and associated with substantial morbidity and mortality. They also include a couple procedures that Medicare is thinking of including in the readmissions reduction program. What we found was quite striking–the best hospitals, those with the highest volume and the lowest mortality rates, had much lower readmission rates. Unlike medical conditions (where the relationship is often heading in the wrong direction) the story on the surgical side seems pretty different. See figures below.
Why would this be? It’s likely because when people are readmitted after surgery, they are coming back for surgical complications. Good hospitals don’t just have lower mortality rates, but they also likely recognize their complications and manage them early, before the patient is discharged.
Some complications, of course, don’t show up until after the patient is discharged. Here too, good hospitals may manage things differently than poorer quality ones. At high quality surgical hospitals, it may be that every patient is getting seen soon after discharge, and complications get recognized and treated in proactive ways that ward off rehospitalizations. We don’t know what these best practices are, but whatever the mechanisms may be, it seems that some hospitals do a better job of this than others, which is no surprise. The challenge is figuring out what these high quality hospitals are doing differently.
Some hospitals have intuitively figured this out. At Brigham and Women’s Hospital in Boston, readmissions were recently added to weekly Morbidity and Mortality (M&M) conferences. Each readmitted patient is carefully discussed and the causes for the readmission probed. If the readmission was preventable, surgeons discuss what might have caused it – whether it was due to an intra-operative technical error, a systems error, or an error in management or communication in the post-operative course. By treating surgical readmissions as a quality measure with the same gravitas as a complication or mortality, the message is clear – it may not be possible to get perioperative mortality or complications to zero, but there has to be a ceaseless effort to get as close as possible.
Moving forward on surgical readmissions
The Medicare readmissions prevention policy has been controversial because there is a sense that we put the cart before the horse. Before understanding what really drove readmissions or how we might prevent them, policymakers jumped in, feet first, into penalizing hospitals that had high readmission rates. The intentions were good, but the data were lacking. The evidence so far says readmission rates are falling, but the cost of the effort has been high. We are penalizing those who care for the sickest and most vulnerable patients.
The data on surgical readmissions, on the other hand, is far more reassuring and reminds us why we need good data. The evidence here is much clearer: when we go after surgical readmissions, we are going after poorer quality care. Right now CMS has proposed two surgical procedures—our data suggests that they can broaden their efforts to include many more. Because the bottom line is if the readmissions reduction program can motivate hospitals to avoid these readmissions by improving surgical care, we can have better outcomes while saving money. And that would be good news all around.