Holding PCPs Accountable for Readmissions May Be Misguided

Marcia Frellick

May 22, 2019

Average hospital readmission rates associated with individual primary care physicians (PCPs) show almost no variation, so incentivizing PCPs to change practice to lower the rates may not make sense, new research indicates.

Siddhartha Singh, MD, MS, an internist and associate professor at the Medical College of Wisconsin in Milwaukee, and colleagues included in their analysis 565,579 hospital admissions in Texas between 2012 and 2015 and 4230 PCPs. Their findings were published online May 20 in the Annals of Internal Medicine.

The researchers looked at what primary care factors could influence readmissions and they adjusted for all for which they had data, including patient and hospital characteristics. Then they measured what effect individual PCPs had on the rates and found almost no effect.

"Nobody had done this kind of research before," Singh told Medscape Medical News. "What we found was incredible."

Between 2012 and 2015, the average risk-standardized rate of 30-day readmissions was 12.9%. Of the 4230 PCPs, only one physician had a readmission rate that was significantly higher than the 12.9% and none had a significantly lower rate. The 10th and 90th percentiles of readmission rates for PCPs were 12.4% and 13.4%, respectively, and each varied from the average by only 0.5 percentage points.

"Whatever primary care physicians are doing in their regular practice is really not impacting readmissions that much," Singh said.

MIPS Makes Assumptions About PCPs

That finding has policy implications, the authors write, especially for pay-for-performance programs such as the Merit-based Incentive Payment System (MIPS), a mandatory program launched by the Centers for Medicare and Medicaid Services in 2015, which assumes that rewarding or penalizing PCPs for the way they practice will lower readmission rates.

The researchers also discovered a second problem with the MIPS assumptions, given the results of their study. The program applies to groups with 16 or more physicians who together have more than 200 admissions per year.

But because the differences are so small among individual PCPs, as this study shows, the sample size to detect a difference between low and high performers would need to be prohibitively large — "3500 admissions per physician at minimum before you could detect differences in readmission rates we were finding in the real world," Singh said.

Even most groups couldn’t generate that number. "Only the extremely large groups would be able to generate 3500 admissions a year," he noted.

The authors focused this study on primary care physicians because care by hospitalists and by emergency department (ED) physicians had already been studied.

Studies have shown that risk for readmissions does not vary by individual hospitalists. Singh and colleagues' previous work also showed that risk for readmission varied moderately but significantly among ED physicians.

"The only place we found variation was in the emergency department," Singh explained.

ED May Be Better Place for Incentives

Singh says this study's conclusions indicate, therefore, that pay-for-performance incentives and quality improvement programs may be better placed in ED care.

Several factors may explain the variation among ED physicians, he said.

ED doctors need to make quick decisions based on limited amounts of information. They are often overloaded with patients and have challenges in getting in touch with physicians who know the patients best, he noted.

"If you put these 3 things together, it starts making sense as to why there's so much variation in the ED department with regard to the readmission discussion," he said.

"Hospitals are held accountable for patients they discharge. And primary care providers are held accountable for patients they take care of during the year. The ED is not held accountable for patients they admit," Singh said.

Study Limitations

A limitation of the paper is that the study population was fee-for-service Medicare patients who lived in Texas so it is unclear if results would be applicable to younger patients in more geographically diverse populations. The researchers also could not determine whether readmissions were avoidable or unavoidable.

The researchers also acknowledge that this study is not able to conclude definitively that incentives and punishments for PCPs to improve practice won't work.

It is possible, but less likely, they write, that PCP practices are uniformly poor with opportunity for improvement for all.

Singh reports personal fees from AstraZeneca, outside the submitted work. The remaining coauthors have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 20, 2019. doi:10.7326/M18-2526. Abstract

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