First Posted at The Hospitalist Leader on 3/18/2013
For readers not familiar with Ashish Jha’s prodigious output, his published work focuses on quality measurement, and in particular, CMS’s Hospital Readmission Reduction Program (HRRP). Two of his papers were released this month: A Path Forward on Medicare Readmissions (NEJM), and Insurance Expansion In Massachusetts Did Not Reduce Access Among Previously Insured Medicare Patients (Health Affairs). He also writes a first-rate blog at An Ounce of Evidence, which I highly recommend. A current post on the 30-day readmit rule continues to garner attention and speaks unambiguously on the subject.
He generously offered to answer a few questions for the blog:
1. With the recent releases of papers by Krumholz and Lindenauer , the view of hospital mortality and readmission rate association may wane .* Or so we think. In your NEJM commentary, you discussed how CMS might proceed. Could you expand a bit more and place the new findings in context?
The Lindenauer paper simply says that area level measures of income inequality is not associated with mortality rates, but is closely and strongly linked to readmissions. I don’t think that the Lindenauer paper sheds direct light on the mortality-readmission relationship, only an indirect one.
The Krumholz paper is more interesting and on point. It finds that for AMI and pneumonia, there’s not much of a relationship, although there is one for CHF. And, the relationship is pretty strong, especially among the very best hospitals (i.e. those with the lowest mortality rates). We also see, when we look at some of the best hospitals in the country (the US News top 50, for instance) that they tend to have very low mortality rates and very high readmission rates. Finally, we have good evidence that big academic teaching hospitals have low risk-adjusted mortality rates – but tend to have higher than expected readmission rates.
So, while the Krumholz paper is helpful and tells us that it is possible to be both low mortality and low readmissions, it doesn’t prove that there isn’t a tradeoff. My sense is that the best hospitals in the country have been paying close attention to inpatient and short-term outcomes (mortality) and therefore, their patients, who tend to be sicker and poorer, tend to come back more often.
2. On readmit penalties, a common thread in your writing concerns the absence of adjustment (and appreciation) for patient socioeconomic status and burden of illness. Readers might scratch their head, and think “of course.” What did CMS miss here, and how should they advance to generate more understanding from puzzled providers?
There’s a big debate about whether you should “adjust” for SES when it comes to quality measurement. I tend to think that you should NOT adjust quality measures for SES – hospitals don’t get credit for providing lousy care to poor or minority patients. However, I’ve made a case in a recent blog that readmissions are not a quality measure. Readmissions are driven primarily by the social context of their home and community life. While it may be fine to ask hospitals to be accountable for whether patients have good social support at home or not, suggesting that the hospital in Scarsdale, New York (think high SES) has the same challenges on this metric as the hospital in the Bronx (think low SES) is silly.
CMS has been confused about whether to think of readmissions as a quality measure or not (its not). Therefore, they have been stuck on the argument that one should not adjust or give credit to hospitals that care for lower SES patients.
3. The NQF upheld their new all-cause hospital-wide readmissions measure endorsement this week. Many physicians do not know about the metric. How could hospital assessments change with this measure, and describe the departure from the CHF, MI, and pneumonia triumvirate we have gotten to know and love? Much to do about nothing or do we need to raise our level of unease?
I actually think moving to an all-cause hospital-wide measure is better. There’s nothing special about the classic triumvirate and of course, efforts to reach out to patients and ensure that they have good transitions, timely follow-up, etc. should be afforded to all patients. It’ll also help with the small sample size problem.
Most people don’t realize – but CMS dramatically “shrinks” hospital performance on the readmissions and mortality measure based on the hospitals’ sample size. So, for a small hospital, the rate you see reported by CMS is almost completely comprised of the national mean….their own data contribute very little to their own rate! This can be frustrating to hospitals that want to improve – no matter what they do, they may see very little change in the rate that CMS will report. The hospital wide measure improves sample sizes and helps alleviate (though not eliminate) this problem.
4. With the presidential campaign, most folks connected the dots on the Affordable Care Act and the Massachusetts 2006 health expansion. Assuming patterns hold, primary care access will tighten nationwide as more individuals receive health coverage. You chose to examine preventable hospital admissions as a proxy for lack of primary care access in your Health Affairs paper. Talk about your choice. As hospital-based providers, should we fear a dearth of primary care providers in our community and more misapplied measurement?
I hope that we don’t see a lot of extra pressure on hospitals because of a dearth of primary care. The truth is that while we may not have enough primary care physicians based on traditional models of healthcare delivery (every patient must be seen by a doctor in the office), if regulators and policy makers are smart, they will allow the system to be more flexible and innovative. We have plenty of providers – NPs, Physician Assistants, etc. And, we increasingly have technology – not just EHRs but also telemedicine. If we can be smart about how we use them, we should be able to handle the influx of new patients.
5. What kind of response have you gotten from your commentaries? You have a unique voice and have been banging the drum for some time. I would think folks understand your points, but perhaps behind closed doors, do not know how to translate your findings into fixes. Conversely, do you think different schools of thought exist on meting out readmit penalties?
The responses I’ve gotten have been really invigorating. You know, when you publish a paper – you might get some press for a few days, but its never clear who reads it (if anyone) and whether it has generated a discussion. The blog has been great because when coupled with social media (especially twitter), I have a much clearer sense of how people are reacting to what I write.
I’ve tried to be very concrete, whether its about readmissions or anything else, about what policymakers should do. And, I try to be evidence-based when I can. I still talk about things in the absence of evidence – and try to be clear that’s what I’m doing. Finally, when evidence does come in, it turns out that sometimes I was right (amazingly) and sometimes, I was wrong (less surprising). I try to evolve with the evidence. In my most recent blog about readmissions, I admit that I was surely too negative about this measure. Its still a little bit of a distraction from what really matters (imagine if we were paying this much attention to patient safety – we could save lives and save money) but it clearly has had some benefits.
*Many folks assumed an inverse relationship, i.e., motivated hospitals would care for sicker patients or focus resources on rescue care. Due to unfavorable patient selection, these institutions would have higher mortality rates and fewer patients to readmit. Whether to assess the two outcomes independently versus dependently still needs clarity–along with the CMS penalties that might accrue.
UPDATE: The Medicare Payment Advisory Commission (MedPAC), the independent body created to advise congress on Medicare, meets twice a year. While their findings have no binding authority, legislators take their reports seriously. The material reads easily–often better than journals–and chapter three in the March report on inpatient care reviews topics you encounter frequently. In particular, a pdf presentation given during the meeting focused on the HRRP. You will find them both helpful.