Readmissions penalties may be unfair

Hospitals may have less control over readmissions than clinicians, administrators or federal regulators would like to believe, new research suggests, meaning that the readmissions penalties imposed by the Centers for Medicare & Medicaid Services may be inappropriate.

Almost 60 percent of the variation in U.S. readmission rates between 2007 and 2010 was explained by a hospital’s location, with primary care and nursing home access as the second largest factor, according to a study in Health Services Research, supported by the Commonwealth Fund, examining how community factors might influence the readmission rates of hospitals.

Jeph Herrin, senior statistician at the Health Research and Educational Trust, and colleagues examined publicly reported 30-day readmission rates for patients with acute heart attack, heart failure and pneumonia at 4,073 hospitals between July 2007 and June 30, 2010, and compared the rates by county, demographics and access to healthcare services.

Before considering demographics, the type of hospital or characteristics of the area, they found that 58 percent of the national variation in 30-day readmission rates was attributable to the hospital’s county.

In other words, “the results suggest that individual hospital performance accounts for only 42 percent of the variation in pooled readmission rates across the United States,” Herrin and colleagues wrote.

Within that 42 percent, they did find a number of demographic and economic factors associated with either higher or lower readmission rates.

Areas with higher proportions of people who have never married, higher proportions of Medicare beneficiaries, lower educational attainment and lower employment were all associated with “significantly higher” readmission rates, while rural areas and areas with large retiree communities were both associated with lower readmission rates.

The lower readmission rates in rural areas is despite what some have called a “crisis” in rural primary care, with fewer per capita primary care doctors compared to urban areas, and despite finding a link between primary care and readmissions. They found lower readmission rates in counties with more general practitioners and nursing homes.

On the flip side, higher per capita specialists and per capita hospital beds were associated with higher readmission rates.

When hospital ownership, teaching status, safety-net status and patient socioeconomic status were considered, “only slightly more variance was explained, suggesting that these particular hospital factors contribute relatively little to the variation in rates of readmission,” Herrin and colleagues wrote.

How much geography, demographics and access to GPs and nursing homes contribute to readmissions is actually driving readmission rates is hard to say for certain, they cautioned, however, they think the correlation is strong enough to make a few recommendations to CMS, which since last year has been reducing payments to hospitals with high readmissions.

“The current readmission reduction program that aims to penalize hospitals whose readmissions are above a certain threshold may not be appropriate,” Herrin and colleagues wrote. “Instead, other payment methods such as those being tested in the Community-based Care Transitions Program, where community-based organizations receive a bundle payment to cover the costs of services required in the postacute care transition period, might be more effective.”