Are 30-Day Readmission Rules Deadly for Patients?

Leigh Page


September 03, 2019

Agents show doctors what to do. Wadhera says some hospitals have hired staff "whose primary role is to push physicians to not readmit, and preferentially manage patients in EDs and observation units whenever possible."

Upcoding. Hospitals can game the readmissions program by raising the severity of the patient's illness by adding more diagnosis codes, Woolhandler says. Through the risk adjustment, higher severity has the effect of reducing the amount of the penalty.

Hospitals already use upcoding to bring down their mortality rates and avoid mortality penalties, Woolhandler says. She reports that a small hospital recently hired an upcoding service for this reason. Larger hospitals, she adds, have their own in-house upcoding teams.

The Future of Readmissions Programs

So far, the dueling research findings have wrought a great deal of confusion about the impact of the program.

Further study will hopefully clarify which side is right. Krumholz and Wadhera say their groups plan to publish major studies on the HRRP within the next few months.

Because it seems unlikely that the program will end any time soon, critics are looking for reforms.

The desired reforms include putting a moratorium on any new conditions targeted by the HRRP until the problems are better understood, and to make observation and ED stays count as readmissions.

Critics also want to combine the mortality rate with the readmissions rate. This could make low mortality a stronger incentive for hospitals. "Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital," wrote Ashish Jha, MD, MPH, professor of global health and health policy at Harvard University's T.H. Chan School of Public Health, in a JAMA opinion piece.

In fact, combining the two measures has been the subject of recent talks between CMS and representatives of cardiology groups and the American Hospital Association, according to a recent report. One of the doctors at these meetings "expressed hope" that a new combined metric might be introduced later this year, the report said.

Meanwhile, CMS recently implemented one reform of the HRRP, which involves reducing penalties for hospitals with many low-income patients, who have high readmission rates. That reform was initiated by Congress, and it is unclear how much CMS can change on its own—especially since the sought-after reforms are based on findings that are still under dispute.

"I don't think CMS is worried about the readmissions program," Gupta asserts. "MedPAC said mortality does not appear to be going up, which is more consistent with my findings. My guess is that CMS is probably going to keep with MedPAC's interpretation."

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