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Study Finds Patient Characteristics Are a Component in Readmission Rates

Hospitals with high readmission rates may be penalized based on the patients they serve

Although Medicare’s readmission policy is meant to curb unnecessary readmissions, many safety-net hospitals, including academic teaching hospitals, say this is unfair because they take care of sicker, poorer patients. New data show they may be right.

Researchers at Harvard Medical School in Boston found that hospitals are being penalized to a large extent based on the patients they serve. The researchers found that nearly two dozen variables, such as patients’ education, income, and ability to bathe, dress, and feed themselves, explain nearly half of the difference in readmission rates between the best- and worst-performing hospitals.

The worst-performing hospitals, for example, have 50% more patients with less than a high school education than the best performers, according to a Washington Post report about the study, which was published in JAMA Internal Medicine.

Education levels make a difference because many patients who are most likely to be readmitted to hospitals tend to have multiple chronic illnesses, such as diabetes and heart failure. And managing those illnesses requires “a significant amount of health literacy,” said Michael McWilliams, associate professor of health-care policy and medicine at Harvard Medical School, a senior author of the study.

Other studies have looked at the influence of such factors as race, income, and education. But these researchers found a broad set of socioeconomic and clinical characteristics of patients by using nationally representative survey data that was linked to Medicare claims data. These characteristics are not included in Medicare’s penalty calculations, which only adjust for certain demographic characteristics, such as age, sex, and sickness of patients.

Hospitals with the highest readmissions had patients who were “less mobile, had more difficulty with activities of daily living, more chronic conditions, less education, lower income, lower assets, and the list goes on and on,” McWilliams said.

“A lot of these individual factors are very familiar to people on an intuitive level, but we incorporated them all together and asked, how did this actually affect how the readmission rate would look for calculating penalties,” said Michael Barnett, a research fellow in medicine at Harvard Medical School and the study’s lead author.

The bottom line, the researchers said, is that hospitals treating the most vulnerable patients are being deprived of needed resources.

For the fiscal year starting October 1, more than 2,600 hospitals will lose a combined total of $420 million, according to a spokesman for the Centers for Medicare and Medicaid Services (CMS).

One hospital that has been hit with the maximum penalty since the program began in 2012 is Franklin Medical Center in Winnsboro, Louisiana. The 39-bed hospital in a rural part of the state serves a predominantly poor population “that is not very educated,” said hospital administrator Blake Kramer.

“It was absurd and foolish for Medicare to essentially apply a one-size-fits-all penalty program and apply across every single population and every single facility,” he said. “We have a lot of very elderly and very poor people.”

For the coming fiscal year, the hospital’s penalty will be $91,000, he said. The hospital’s budget is about $24 million, and although the county-owned hospital has finished in the black for the last three years, it’s been a struggle, he said.

Asked about the findings of the new study, CMS Chief Medical Officer Patrick Conway said the agency is researching the impact of socioeconomic status on the readmissions penalty program. “We will continue to work with all stakeholders to seek feasible ways to encourage hospitals to reduce hospital readmissions while addressing any unintended consequences, particularly for those hospitals serving dual-eligible and low-income beneficiaries,” he said.

The aim of the program, created under the Affordable Care Act, is to lower costs and improve care by spurring hospitals to do a better job taking care of patients, especially after they leave the hospital. Readmissions are huge and costly — nearly one in five Medicare patients returns to a hospital within a month of discharge, and studies have shown that nearly three-quarters of readmissions are potentially preventable.

Sources: JAMA Internal Medicine; September 14, 2015; and The Washington Post; September 14, 2015

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