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Medicare Plan to Cut Hospital Readmission Is Tied to More Deaths

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A U.S. government program meant to improve medical care and cut costs by penalizing hospitals that repeatedly readmit people with heart failure may have instead increased the risk that the patients would die, a new study suggests.

The policy, called the Hospital Readmissions Reduction Program, was created in 2010 under the Affordable Care Act as one of several ways to use Medicare’s immense buying power to improve care. Under the program, hospitals were reimbursed less when heart failure patients were readmitted within a month.

It did reduce the number of costly readmissions, according to the study, which was published Sunday by JAMA Cardiology. Yet the number of patients who died rose as well. The findings could indicate an additional 5,000 to 10,000 deaths annually across the U.S., said Gregg Fonarow, the senior author of the paper and professor of cardiovascular medicine at the University of California, Los Angeles.

(Related: This ACA Rule Keeps You Out of the Hospital and Saves Billions. Will It Survive?)

“From the standpoint of a clinician that cares for heart failure patients, there is no degree of increased mortality that would be accepted, no matter what the benefits for readmission and cost savings were,” said Fonarow, calling the results serious and alarming. “This finding requires in my opinion immediate action to find ways to mitigate what is clearly an unintended consequence.”

The study wasn’t able to determine the cause of the rising death rates, and others factors than the government program could have come into play, doctors said. But the program could have created incentives that delayed care for some patients, or put them into outpatient care services that weren’t as effective, according to Fonarow.

Heart failure is the most common diagnosis linked to readmissions in the Medicare insurance program for the elderly, with 134,500 newly released patients landing right back in the hospital in 2011 at a cost of $1.7 billion, according to the Agency for Healthcare Research and Quality.

Powerful Incentives

The HRRP program penalizes hospitals up to 3% of every Medicare dollar for excessive repeat stays, 15 times more than the 0.2% penalty levied against those with high mortality rates, Fonarow said.

The researchers analyzed 115,245 patients at 416 hospitals in the American Heart Association’s Get With the Guidelines-Heart Failure registry from January 2006 to December 2014. They looked at readmission and death rates before and after the program began in 2012.

The readmission rate within one year fell to 56.3%, from 57.2%, but the mortality rate within one year increased to 36.3%, from 31.3%.

U.S. health officials touted the program as an example of how government incentives could make care more efficient. In a 2015 medical journal publication, then Secretary of Health and Human Services Sylvia Mathews Burwell called it part of a national effort to use “incentives for higher-value care, fostering greater integration and coordination of care and attention to population health.”

Medicare officials didn’t return emails seeking comment.

More study needs to be done to find out if it’s the program that’s boosting deaths, or if there’s something else changing about heart failure care, said Nilay Shah, chair of health policy research at the Mayo Clinic in Rochester, Minnesota. An earlier study similarly found elevated death rates in heart failure patients, but not those who had a heart attack or pneumonia, complicating the issue, he said.

“It really makes you think about it; is this a policy issue or is there something else going on with these conditions, or with how these patients are managed,” he said. “I don’t know that we have definitive information to say this is a bad program.”

Other Factors

The program was also more likely to penalize hospitals caring for the poorest and most vulnerable patients. Cutting financial resources for hospitals that need it the most could lead to further reductions in staffing and program levels, he said.

“It’s created a whole set of incentives that are open to potential gaming and other decisions that might not be aligned in the patient’s best interest,” Fonarow said, emphasizing that the any ill effects weren’t deliberate. “The patient who dies early after hospitalization can’t be readmitted.”

Hospitals need to determine if heart-failure patients are missing some care, such as closer control of unrelated conditions, said Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association.

“Are there patients who shouldn’t be included because their health is too fragile, patients we shouldn’t be trying to keep out of the hospital?” she asked. “We need to quickly answer those questions.”

— Read Insiders: Hospital Discharge Planning Is Still a Mess on ThinkAdvisor.

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