By Paul Levy
First Posted at Not Running a Hospital on 3/7/2013
@ashishkjha Ashish Jha is easy to distinguish from many health care policy people in that he is “an advocate for the notion that an ounce of data is worth a thousand pounds of opinion.” Unlike yours truly, he also has access to tons of data, so when he speaks, it is worth listening.
In a recent post on The Health Care Blog, Jha draws the following conclusion:
The debate around the readmissions measure has come to the forefront because of the CMS Hospital Readmission Reduction Program, which penalizes hospitals for “greater than expected” readmission rates. It has raised the question — does a hospital’s 30-day readmission rate measure the “quality of care” it provides? Over the last three years, the evidence has come in, and to my read, it is unequivocal. By most standards, the readmissions metric fails as a quality measure.
[I]f one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).
But does the program help at all? Here’s where Ashish goes anecdotal on us (but at least he admits it!):
So, given its poor test characteristics, can we justify using the current hospital readmissions measure to grade hospitals on quality? I don’t think we can. However, here’s where my own ideas have evolved. … [T]he 30-day readmission measure may be a good way to promote accountability in healthcare.
In conversations with colleagues and friends, the readmissions penalty program seems to have gotten some hospitals to think outside of their four walls. Hospital leadership has started to rethink the role of the hospital. Hospitals are building relationships with community-based organizations. Some are creating follow-up clinics while others are calling all the patients who are discharged to make sure they are doing OK at home.
And the personalized summary:
The readmissions program seems to be, for some hospitals, having a positive effect. Will it pay off? Will we see a real, sustained change in the way they provide care to patients after they are discharged? I hope so. But remember – some of the best hospitals in America have the highest readmission rates, almost surely because they care for sicker, poorer patients. In the current business model, they are doing things right – taking good care of the patient while the patient is in the hospital. It’s fine to ask these hospitals to change their business model and to become accountable for what happens to their patients after they are discharged. But, let’s not call them bad hospitals or suggest that they are providing poor quality care. There is no evidence that they are.
How refreshing to hear from an honest analyst, someone who distinguishes between conclusions based on evidence, hypotheses based on anecdotes, and hopes based on societal ethical standards! The only thing missing from this article, in my view, is the “so what?” question. What should we actually do?
I think the answer comes from transparency. Just post, for the world to see, the readmission rates of all hospitals by clinical specialty and let admininstrators and doctors compare their performance to others. Even without financial penalties, the inherent competitiveness of people in this field will cause them to evaluate their work and try to do better, consistent with underlying standards of quality. If CMS wants to provide a financial incentive, give a small bonus to hospitals that voluntarily post such results for each attending physician in real time, not months later. Then, you’ll see changes in practice patterns!
But this approach is not likely to be considered, much less adopted. Federal and state policy is designed by other people. Look at this comment by another health care policy person:
Stuart Altman, a professor of national health policy at Brandeis University [and chair of the Massachusetts Health Policy Commission Board], said he gets questions from hospital chief executives and chief financial officers asking “why are we getting penalized when we take care of the patient?”
“I tell them, ‘you are big, rich and powerful, and you have the ability to resolve the problem and you will be part of the solution whether you like it or not.’ “
“There are appropriate readmissions, such as related to different ailments or an unforeseen health event unrelated to the first admission,” Altman said. “Hospitals are not penalized in those situations.
“However, there also are non-appropriate readmissions that can be benchmarked and compared with peers and the community.”