Alex Azar’s medical woes shine a light on readmissions

By Dan Diamond
POLITICO Pulse, April 20, 2018

On Monday, the HHS secretary was discharged from the hospital with a common intestinal infection known as diverticulitis. By Wednesday, he was back — the most high-profile hospital readmission in some time.

More than a few PULSE readers noted the irony: HHS is actively working to curb readmissions, even as the agency’s leader needed one himself.

The Affordable Care Act created a program to penalize hospitals with high readmission rates, which Obama officials argued would boost quality and cut costs.

And readmission rates have fallen — but there’s evidence that it’s partly because hospitals changed how they document patients, not necessarily improved care quality.

“I’ve always found the focus on readmissions to miss the bigger point,” says Harvard’s Ashish Jha, arguing that the real issue is how the U.S. health care system encourages hospitals to quickly send patients home. That approach has positives (many patients would prefer to recover at home) and drawbacks (some patients’ illnesses inevitable get worse).

Diverticulitis is also a common condition with a relatively straightforward course of care, notes Jha, a practicing internist. When a patient gets readmitted, “it’s almost never a failure of care coordination or fragmentation,” he adds.…

People who have conditions that require hospitalization frequently develop related problems after they are discharged from the hospital and then require readmission. Most of these readmissions are unavoidable.

Occasionally readmission is avoidable if lapses in followup occur such as ensuring that patients receive medications that are required to control their medical conditions. But even in those instances it often is not the fault of the hospital. The patient can have many reasons for being non-compliant, and the hospital can do only so much to improve that compliance. Of course, some hospitals, especially those serving as safety nets, have a greater population of patients who are less likely to be compliant regardless.

Yet hospitals are being penalized when their 30 day rates of readmissions are above a modest threshold. Many of these penalties are unfair since they are based on mere chance of falling on the wrong side of the bell curve.

Patients who return may not be formally readmitted, often to avoid the risk of a penalty, even though they may be treated as if they were. This has potential financial consequences for the patient since coverage is based on outpatient rather than inpatient payment rules. It may also disqualify a patient for convalescent facility care should it be required.

Why don’t we just pay fair prices for care that patients need? That is what a well designed single payer system should do. HHS Secretary Alex Azar should contemplate whether or not it was fair to potentially penalize his hospital simply because his physician thought that he should be readmitted.

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