Penalizing Hospitals for Readmissions

I’ve posted to this blog often about the difficulty in measuring quality in health care: RACS and Quality of Care, Novice to Expert, Computers and Language Translation, to name just a few. So it’s really nice to see another blogger dealing with the same issues.

A surgeon blogging under the name Skeptical Scalpel, MD, has posted on KevinMD “Is it really fair to penalize hospitals for readmissions?” Medicare wants to reduce hospital payments when patients are readmitted within 30 days. There’s a certain Mad Hatter and March Hare relationship here. Medicare and insurances have established that patients can only remain in acute beds for three days. O.K.  Then Medicare decides to punish hospitals for readmissions by cutting reimbursements when patients are readmitted within 30 days for the same diagnosis.

The underlying assumption is that hospitals should be penalized for readmissions because there’s something wrong with the care the patient received. But the reality is that there are simply no reliable measures of quality of care. Skeptical Scalpel, MD, says it well:

Assessing quality of care in hospitals is a difficult task. People like me have complained about focusing on processes such as the Surgical Care Improvement Project because adherence to process measures does not always correlate with good outcomes. However, processes are much easier to track than outcomes.


The problem with outcome measures is that experts can’t agree on which ones to measure. Even something as seemingly straightforward as death can actually be complex. A 2010 paper in the British Medical Journal on this subject was reviewed in a blog, which pointed out the difficulties with death as a benchmark. This holds true even when death is adjusted for risk.

What really happens in this Mad Hatter and March Hare environment is that patients are often discharged from acute care beds sick, or at the very least no where near recovered from whatever prompted their admission. The result: the patients wind up going to the ER or another physician, often sicker than when they were discharged, or sick from a complication of whatever they were originally admitted, and the patient is readmitted to the hospital.  Somehow this is the hospital’s fault?

As the Mad Hatter says, “Tea time!”

Medicare has never understood that punishing hospitals and physicians for providing needed care in no way saves money.  We know that preventive care saves health care dollars in the long run.  Allowing physicians to treat patients, to make decisions in cooperation with their patients about medical care, even if it means staying in an acute care bed more than three days, saves money in the long run.

Should Medicare oversee the care they pay for? Absolutely.  But Medicare also needs to understand that patient outcomes are variables which cannot be easily assessed as measures of quality. No checklist based upon outcomes can accurately measure quality of patient care.

Until Medicare and those who oversee the system understand this important variable, effective reform based upon quality health care will elude us all.

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