ACA penalties resulted in steep decline in 30-day readmissions, and did so without increasing mortality risk.
Steps to lower readmissions may have also reduced mortality risk: better preparation of patients and families for discharge; improved integration, and coordination of care from hospital to home.
Excerpt: “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 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.”
“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.”
WBB Take: A focus on quality of care can reduce cost and improve outcomes. With high inpatient costs, CMS chose to incentivize Medicare and Medicaid healthcare providers to reduce inpatient length of stay (LoS). This incentive raised concerns that hospitals might focus on LoS rather than medical condition. The foremost concern was that a focus on LoS might result in premature patient discharges, thus raising the risk of increased morbidity and mortality. As a balancing measure, CMS also incentivized reduction in 30-day readmission rates.
Although there are some conceptual problems with using 30-day readmission as a healthcare quality flag, it is nevertheless true that many readmissions reflect quality issues including poor diagnosis, ineffective treatment, medical mistakes, and missed opportunities. Further balancing measurement would logically be to check that patients were not staying away from the hospital, but still experiencing increased morbidity and mortality as the result of premature discharge.
This study confirms that hospitals seem to have responded to the incentives. While LoS numbers have been reduced, renewed focus on quality has resulted in significantly lower readmission rates, and stable or lower mortality rates.
Cited by Matthew Loxton