Accountability Without Responsibility?

PHO-10Sep15-267645Earlier this week Rep. Jim Renacci (R-Ohio), together with a bipartisan group of 25 other House members introduced H.R. 4188, the Establishing Beneficiary Equity in the Hospital Readmission Program Act. Text of the bill is not available through the Library of Congress yet, but from what has been discussed publicly its purpose is to provide hospitals with financial relief from Section 3025 of the Affordable Care Act: Hospital Readmissions Reduction Program.

The hospital readmissions program has received a great deal of discussion, but with implementation beginning last year hospitals that exceeded the excess readmission ratio in their 2013 fiscal years are now seeing reductions in Medicare reimbursement of up to 1%. Unless those hospitals are able to improve that ratio the potential payment reduction could increase to 2% next year and 3% the year after. For an organization already struggling with tight margins a 3% reduction in revenue that represents approximately 20% of total revenue without any commensurate reduction in costs has serious clinical and operational ramifications.

Previous PolicyPub posts on Hospital Readmissions:

The Trouble With Avoidable Readmissions ~ February 2012
Is Focus on Hospital Readmissions Misguided ~ May 2012
Update: Hospital Readmissions ~ February 2013

Not unsurprisingly, H.R. 4188 has already garnered rather broad industry support from the likes of hospitals and the trade associations representing them – i.e., anyone standing to benefit from more revenue as opposed to less.

As I understand it H.R. 4188 doesn’t provide blanket relief for hospitals affected by the readmissions program. Rather it is intended to recognize and adjust for the penalty impact of caring for patients who are financially unable to afford post-acute housing, services and care in a manner that would otherwise facilitate their ability to avoid a readmission. And the logic goes that if all those altruistic hospitals are unselfishly willing to open their doors to care for the poor, well then penalizing them for that willingness is grossly unfair.

But hold on. The readmissions reduction program wasn’t thought of, planned or designed in a vacuum. The challenges associated with securing and providing affordable post-acute housing, support services and care has been a widely recognized problem that predates Medicare and Medicaid. The purpose of the program is to provide incentives for hospitals to take a more active and holistic approach to managing patient care post-discharge – regardless of the patient’s wealth and income. No penalties – no incentives.

The program wasn’t designed to change the type of patient cared for – but the manner and scope of patient responsibility. What hospitals have argued in return is that they are being held accountable for a scope of services and care for which they have not historically been responsible (accountability without responsibility). CMS’s de facto response is pretty straight forward: then don’t accept Medicare anymore. If hospitals want to continue benefitting from taxpayer dollars, they will have to help find ways to reduce the costs of healthcare subsidized by those taxes – and not just the costs that manifest inside their walls (or more properly, their historical sphere of influence).

We are just now beginning to see the benefits of the readmissions program’s incentives manifested in efforts of hospitals across the country to integrate with post-acute/long-term care provider organizations. That has required their gaining a better understanding of PA/LTC patient care models, understanding the challenging dynamics of care transitioning and working with physicians to better appreciate the post-acute challenges they have wrestled with for generations.

So now that hospitals are finally taking notice of the potential cost and quality benefits of post-acute care integration we want to tell them “ah, never mind – it’s too hard?” Really?


Update: Hospital Readmissions

Hospital Readmissions continues to be a driving topic of concern, debate and contention in the healthcare industry.  It also continues to be an area of great interest for potential partnerships between acute and post-acute care organizations.  Whether that interest is warranted based upon expected improvement in outcomes and cost reductions remains to be seen.

JAMA Study: Assessing Program Risk
On Tuesday of this week the Journal of the American Medical Association published a study, which looked at the relationship between risk-adjusted mortality and 30-day hospital readmissions.  The reasons for testing this relationship are because of concern that artificial incentives will drive behaviors with unintended consequences.

First, the concern is that hospitals may invest resources to lower readmissions for targeted conditions at the expense of quality care for other conditions.  Second, there is concern that patients may not cared for in an environment that is determined by clinical needs and requirements, but instead by financial considerations.  For those who believe these concern are overstated the results of this research will serve to reinforce their perception. 

Data was analyzed for Medicare beneficiaries admitted to hospitals between July 2005 and June 2008 with a heart attack, heart failure and pneumonia. These are the three conditions hospitals are now being penalized for 30-day readmissions under the Medicare Hospital Readmissions Reduction ProgramAccording to the study, “risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.”

RWJ Foundation: Revolving Door
Another report released this week, by the Ro
bert Wood Johnson Foundation, found that hospitals and their partner relationships made little progress from 2008 to 2010 at reducing hospital readmissions for elderly patients.  Using new Medicare data from the Dartmouth Atlas Project, researchers found , “one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while one in six patients returned to the hospital within a month of leaving the hospital after receiving medical care. Patients were not significantly less likely to be readmitted in 2010 than in 2008.”

The report also shares findings from interviews with patients and providers that sought to better understand the root causes of patient readmissions.  While some portion of those readmissions were either anticipated or necessary, there were also a significant number of readmissions that could primarily be attributed to non-clinical considerations, such as discharge planning, the individual’s support system, care coordination and the availability of primary care post-discharge.

So what to make of this? Research is continuing to support the hypothesis that cost savings are achievable by creating better alignment of care requirements and care settings without sacrificing quality.  The ways in which providers achieve such savings, however, are no clearer today than they were several years ago.  Also up for debate is whether the Hospital Readmissions Reduction Program is providing a meaningful incentive to drive innovation – or whether providers are reacting to market realities (likely some combination thereof).

What does not seem to be up for debate is the reality that proactive healthcare providers are pushing integrated delivery models that seek to facilitate better resource alignment.  Are you one of those organizations?




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