By Mitchel L. Zoler
Internal Medicine News, September 20, 2017
U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.
“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 69% of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.
“The most concerning question we can ask is whether inappropriate discharges from emergency rooms and observation units” is a driving factor behind the mortality rise despite a readmissions drop, said Dr. Abdul-Aziz, a cardiologist at the University of Michigan in Ann Arbor.
These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.
Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.
“CMS thinks that policy reform is the way to improve outcomes of patients hospitalized for heart failure. There was no evidence, no results from randomized trials, but they pushed it on the country. And it has reduced readmissions. But there have been unintended consequences of gaming the system, of keeping patients out of the hospital and giving them outpatient status, and these data raise concerns because 30-day mortality went up,” said Dr. Fonarow, professor and cochief of cardiology at the University of California, Los Angeles. “We should all be extremely concerned about the unintended consequences of payment reform strategies” that aim to improve the management of patients with heart failure.
By Don McCanne, M.D.
Supposedly application of policy science provides higher quality care at lower costs, but in the case of heart failure, with no evidence, policy decisions were made to penalize hospitals 3 percent of their payments if their 30-day readmission rates went up, but only 0.2 percent if the patients died. Thus CMS rewards hospitals that follow the dictum, “Don’t readmit them, let them die.”
One of the criticisms of using Medicare as the model for a single payer system is its large centralized bureaucracy. Policy decisions often seem quite distant from decisions that should be made between health care professionals and their patients.
The Canada Health Act is only 14 pages and it would be half that except the text was repeated in French. The Canadian Medicare system is administered on the provincial level rather than through Ottawa. Likewise, in the United States it is recommended that administration be more decentralized – moving it from Washington, DC to greater state or regional control. That is one of the major reasons that we refer to an Improved Medicare for All.
Imagine making a decision for readmitting a patient with heart failure. Wouldn’t it be far better making that decision based on clinical need rather than being based on a penalty system out of Washington? Not that physicians would do such a thing, but then why do the numbers suggest that they do? An obvious solution is to shoo away the policy bureaucrats and simply do what is right for the patient.
Canada Health Act:
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