Are 30-Day Readmission Rules Deadly for Patients?

Leigh Page

Disclosures

September 03, 2019

What happened was that in 2011, just before the HRRP started, Medicare raised the number of reportable diagnosis codes from nine to 25, Ody says. This meant that hospitals could add extra diagnoses to their billing, making HRRP patients appear to be sicker when in fact they were no sicker than before.

Ody and colleagues also produced a second finding, using another research methodology. It showed that the readmissions rate fell very little or perhaps not at all.

This part of the study compared readmission rates for HRRP-targeted conditions with rates for conditions not targeted by the HRRP and thus not subject to penalties. This part of the study determined that there was very little difference in the readmission rate between these two groups.

Ody says this could mean that hospitals were also lowering readmissions for conditions not covered by the HRRP—a phenomenon called "spillover"—or it could mean that hospitals simply did not cut many readmissions for HRRP conditions.

As a result of the study, "I would urge renewed skepticism about whether hospitals' processes to reduce readmissions are in fact working," Ody says.

Krumholz, however, questions Ody and colleagues' findings. For example, he denies that his earlier studies did not take the coding change into account. "We knew about the coding change; it wasn't a secret," he says. "We just didn't see it making as much of a difference."

He also sees a contradiction between the two studies challenging the HRRP. Ody and colleagues' study suggests that the HRRP has had little impact on readmissions, but Wadhera and colleagues' study suggests that the HRRP was so effective that it killed people, Krumholz says.

How Could Hospitals Be Gaming Readmissions?

The findings by both Ody and Wadhera and their colleagues lend some credence to concerns that hospitals are gaming the readmissions program. If the readmissions rate didn't fall by very much and mortality is linked to higher readmissions, hospitals may not really be trying to help patients keep well after they've been discharged.

Wadhera and Woolhandler point to the following gaming strategies, two of which have already been mentioned:

Keeping patients in the ED. HRRP patients present mainly through the ED, where they can be given treatment for hours rather than be admitted.

Using observational status. Some 10% of returning HRRP patients were admitted for observational stays, according to a 2015 study that Woolhandler coauthored, based on CMS data.

However, there are other reasons for using observational stays, such as to avoid a reimbursement denial for improper admissions identified by recovery audit contractors working for CMS.

Using EHR alerts. Many electronic health record (EHR) systems have alerts indicating patients who are returning to the hospital in less than 30 days ago. Once alerted, doctors would be able to make sure these patients don't go into a regular hospital bed.

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