Are 30-Day Readmission Rules Deadly for Patients?

Leigh Page

Disclosures

September 03, 2019

Moreover, Wadhera and colleague's study showed that the death rate rose primarily among patients who had not been readmitted to the hospital. Wadhera says this suggests that these very sick patients had either not been treated at all or had received less robust treatment on observation status or in the ED.

On the basis of these findings, the HRRP "may have resulted in 10,000 more deaths among patients with heart failure and pneumonia," Wadhera and his coauthors wrote in an op-ed piece in the New York Times in December.

A former Obama administration official who helped create the HRRP came to the program's defense. The estimated deaths in the Times piece were "unduly alarmist," wrote Peter R. Orszag, former director of President Barack Obama's Office of Management and Budget, in January.

However, Orszag left open the possibility that the critics were right. "The weight of the evidence to my reading still suggests some benefit from the policy in reducing readmissions and no harm in mortality," he wrote, "but that conclusion must be tentatively held for now."

Despite the new studies, the jury is still out on the link between mortality and the HRRP, says Atul Gupta, PhD, a readmissions researcher who is assistant professor of healthcare management at the Wharton School, University of Pennsylvania, in Philadelphia.

Gupta says many of the studies linking high mortality to the HRRP don't account for other factors that could raise mortality, such as a growing number of patients in Medicare Advantage plans, a program that is not part of the HRRP. Medicare Advantage, which is growing rapidly, tends to attract healthier people. This leaves traditional Medicare with sicker people and pushes up the mortality rate, he says.

Did HRRP Really Reduce Readmissions?

Meanwhile, two other studies challenge the HRRP on a different front. They suggest that the HRRP accounted for much less of a reduction in readmissions than previous studies had shown.

Unimpressive reductions in readmissions suggest that hospitals are not putting in the hard work needed to make sure patients get better and don't need to go back to the hospital.

Previous studies had indicated that the program reduced admissions by 1%-2% or by as much as 5%. But a February 2018 study found that the actual reduction was only one third of that, and a January 2019 study put the reduction at about one half of the previous rate.

The previously estimated reductions "appear to be illusory or overstated," the authors of the 2019 study said.

The lower percentage of readmissions found by the new studies had to do with calculating the risk adjustment for sicker patients. Owing to the risk adjustment, when readmitted patients have a higher severity of illness, the calculated HRRP rate for the hospital is lower.

But the studies found out that severity of illness among HRRP patients suddenly bounced up around the time of the HRRP launch, says Christopher Ody, lead author of the study and a research assistant professor of strategy at the Kellogg School of Management at Northwestern University.

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