By Will Boggs MD
(Reuters Health) - Hospitals appear to be treating Medicarepatients in emergency departments (EDs) and observation areas toavoid readmissions and the financial penalties associated withthem, according to a new U.S. study.
"We have noticed that patients who come back to the hospitalshortly after discharge are increasingly being treated in the ERor as observation stays - many of our colleagues across thecountry have also conveyed that they are being nudged to providecare in these settings, to make hospitals' readmission rateslook lower," said Dr. Rishi K. Wadhera from Beth IsraelDeaconess Medical Center and Harvard Medical School in Boston,who led the study.
Since 2012, an initiative by the Centers for Medicare andMedicaid Services (CMS) to improve the quality and value ofpatient care, known as the Hospital Readmissions ReductionProgram (HRRP), has imposed financial penalties on hospitalswith higher-than-expected rates of readmission within 30 days ofdischarge for patients initially admitted for heart failure,heart attack or pneumonia.
In fiscal year 2019, 82% of hospitals received suchpenalties.
Under the program, readmission rates have "declined modestlynationally," Wadhera's team writes in The BMJ. But HRRP does notcount emergency department visits or so-called observation staysas readmissions, so the researchers wondered if total hospitalrevisits for these conditions had really changed or just shiftedcategory.
They used Medicare files to examine not only readmissions,but also treat-and-discharge visits to an emergency departmentand observation stays that did not result in readmission for thethree conditions covered under HRRP.
Between January 2012 and October 2015, the total number ofhospital revisits within 30 days of discharge per 100,000patient discharges increased overall by 23 visits per month, thestudy team found.
This increase was a result of a rise in treat-and-dischargevisits to an emergency department (by 23 visits per month per100,000 patient discharges) and an increase in observation stays(by 22 visits per month per 100,000 discharges). Actualreadmissions, though, decreased by 23 visits per month per100,000 patient discharges during this period.
Results were similar when only first hospital revisits werecounted. These changes were also similar among patients youngerand older than 80 years, among men and women, and among whiteand non-white patients, although increases in observation stayswithin 30 days of discharge were higher among non-whitepatients.
"While the spirit of the HRRP is to push hospitals toimprove discharge planning and care transitions, to reduce thelikelihood of returning to the hospital, mounting evidencesuggests the program has had unintended effects," Wadhera said.
"Our study suggests that health care systems areintensifying efforts to treat patients who come back to ahospital in ERs and as observation stays, potentially to maketheir readmission rates look lower," he told Reuters Health inan email.
"It's not clear whether greater use of ERs to treatpatients, instead of an inpatient stay, has enhanced or worsenedpatients' care quality and experience," Wadhera noted. "Inaddition, observation stays can be associated with highout-of-pocket expenditures, and we need to better understand(whether) greater use of observation stays under the HRRP hasincreased financial strain on patients."
Instead of imposing penalties through the HRRP, CMS "shouldwork with hospitals that consistently struggle with high totalhospital revisits and support tailored improvements in caredelivery at these sites to help reduce unnecessary hospitalrevisits," Wadhera said.
"I am not surprised at all by these results, which actuallyconfirm what my colleagues and I found in an earlier study forNY state Medicare patients," said Dr.Yue Li from University ofRochester School of Medicine and Dentistry, who wasn't involvedin the current study.
"The results somewhat reinforce the concern we had thathospitals may simply use ED and observation stay as a substitutefor inpatient care to avoid CMS financial penalties, rather thanimproving the coordination of post-discharge care and addressingthe real needs for better community support of recentlydischarged patients," Li said in an email.
"The finding in this study that the increase in observationstays was faster for non-white patients is troubling given thatbefore (and after) the HRRP, non-white patients tended to have ahigher 30-day readmission rate," Li noted. "Other vulnerablepatients (Medicaid patients, those with multiple conditions ordisabilities) may also be at a disadvantage under current andfuture Medicare policy changes."
SOURCE: https://bit.ly/2No8Xna The BMJ, online August 12,2019.