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Perhaps unsurprisingly, patients 85 and older are more likely to
return to the hospital within 30 days of being sent home than people
a decade or two younger, according to the analysis of data from
Medicare, the U.S. health program for the elderly and disabled.
But patients also have higher odds of returning soon after discharge
if they lack a high school diploma, have limited income and assets
or have health benefits from Medicaid, the U.S. health program for
the poor.
The findings suggest that Medicare penalties for what’s known as
readmissions under the Affordable Care Act may in some instances
mete out punishment for outcomes that are beyond doctors’ control,
said lead study author Dr. Michael Barnett and senior author Dr.
Michael McWilliams, colleagues at Harvard Medical School and Brigham
and Women’s Hospital in Boston.
“Hospitals are being penalized to a large extent based on the
patients they serve,” the doctors said by email. “Patients admitted
to hospitals with higher readmission rates are sicker and more
socially disadvantaged in a variety of ways than patients admitted
to hospitals with lower readmission rates.”
Under the current penalty system, Medicare deducts 3 percent from
inpatient payments to hospitals with higher than expected
readmission rates, the researchers report in JAMA Internal Medicine.
Expected rates are only adjusted for patients’ age, sex and recent
diagnoses including the one from their hospital stay.
In 2014, the second year of the program, about 2,600 hospitals were
fined a combined $428 million for excessive readmissions, the
authors report.
To get a better understanding of how individual patient
characteristics might influence repeat hospitalizations, the
researchers examined several other variables Medicare doesn’t
consider in determining expected readmission rates – such as
education and income levels, marital status, employment, race and
ethnicity, smoking status and drinking habits.
They linked records from a nationwide health and retirement survey
of Americans over 50 collected between 2000 and 2010 to data from
Medicare claims from 2000 to 2012. The combined analysis assessed
more than 8,000 hospital admissions.
The researchers sorted hospitals into quintiles based on readmission
rates. They found that at least half of the observed difference in
the probability of repeat hospitalizations between hospitals with
the highest and lowest readmission rates might be accounted for by
patient characteristics not currently considered by Medicare.
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When researchers only used Medicare’s criteria comparing readmission
rates, they found the probability of repeat hospitalization was
about 15 percent at facilities with the lowest rates and about 19.5
percent at hospitals with the highest rates.
But when they took another look using more criteria on patients’
medical, social and economic characteristics, the gap between
hospitals with the lowest and the highest readmission rates narrowed
to 16 percent and 18.4 percent, respectively, odds of repeat
hospitalization.
One limitation of the study, the authors acknowledge, is the data
didn’t allow them to calculate how considering individual patient
characteristics might impact readmission rates at specific
hospitals.
Even so, the findings suggest that the current Medicare penalty
system for repeat hospitalizations may put facilities serving poor
communities at a distinct financial disadvantage, Dr. Carl van
Walraven, a senior scientist at the Ottawa Hospital Research
Institute in Canada, noted in an accompanying editorial.
“Differences between hospitals in readmissions may be due to who is
treated rather than how they’re treated,” van Walraven said by
email.
SOURCE: http://bit.ly/1MmPcWX and http://bit.ly/1UT2grE JAMA
Internal Medicine, online September 14, 2015.
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