Readmissions Measures May Unfairly Penalize Hospitals

Steven Fox

June 19, 2014

Medicare claims data for readmissions in surgical patients do not reliably describe reasons for readmission, and this could lead to unfair penalties imposed on hospitals, according to a new study. The Centers for Medicare & Medicaid Services have proposed new all-cause readmission measures that use Medicare claims data to assess readmission rates at hospitals. Under the proposed regulations, hospitals with higher-than-expected readmission rates would be financially penalized.

Now, however, results from a new retrospective review have concluded that Medicare claims data may not accurately reflect why patients are readmitted.

Greg D. Sacks, MD, MPH, from the Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, and colleagues published their findings online June 11 in JAMA Surgery.

The authors focused on 315 consecutive patients who had been readmitted after general surgical procedures during an approximate 2-year period.

They compared diagnostic data on readmissions that had been generated from direct medical review with the administrative diagnoses on those same cases that had been documented in Medicare claims data.

In nearly a third of the readmissions (30.8%), diagnoses listed in Medicare claims data differed from diagnoses listed in hospital medical records.

The researchers note similar discrepancies between how Medicare claims data and clinical data defined unanticipated readmissions. Medicare measures deemed 4.8% of readmissions were planned, whereas hospital clinical records showed 13.7% were planned.

In addition, readmissions unrelated to the previous surgical procedures accounted for 27.1% of the unanticipated readmissions.

"Implementation of this readmission measure may result in unwarranted financial penalties for hospitals," the authors conclude.

In an invited commentary that accompanies the study, David R. Urbach, MD, from the Division of General Surgery, University Health Network, University of Toronto, Ontario, Canada, writes, "H.L. Mencken's observation that 'there is always a well-known solution to every human problem — neat, plausible, and wrong' may well apply to health policy efforts to address the problem of unplanned hospital readmissions." He adds, "[T]he study by Sacks et al makes one point about efforts at measuring readmissions perfectly clear: surgical care is highly nuanced, and surgeons need to be engaged in this process."

The authors and the commentator have disclosed no relevant financial relationships.

JAMA Surg. Published online June 11, 2014. Article full text, Commentary extract

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