Dr. Nelson, a co-founder of SHM and a longtime practice management columnist for The Hospitalist, says a bonus based on readmissions rates might be reasonable, although it’s important not to create incentives that deny the patient a needed return to the hospital in order to ensure that the hospitalist gets the bonus. Competing pressures on performance for both shorter lengths of stay in the hospital and fewer readmissions complicate incentives for hospitalists. “Compensation incentives [bonuses] based on both length of stay and readmissions are problematic, because they could potentially be construed as incentives to deny needed care, so [they] are best avoided,” Dr. Nelson says.
The Wrong Target?
HRRP has generated a huge amount of commentary in the health policy media. Some charge that it unfairly penalizes teaching hospitals and large institutions, as well as those serving a greater proportion of patients with lower socioeconomic status or those with fewer social supports.7
In a New England Journal of Medicine editorial, Dr. Jha and co-author Karen Joynt, MD, MPH, ask “whether the hospital is the appropriate entity to be held accountable for readmissions, given that the events and circumstances that predict readmissions largely take place outside the hospital’s walls.”7 Dr. Jha doesn’t consider readmissions rates a true measure of a hospital’s quality.
“I think the real goal should be improving transitions of care—with better quality measures for assessing good transitions,” he says. “You can improve transitions of care without improving readmissions rates.”
A serious disconnect exists between readmissions penalties and evidence for strategies that might be expected to prevent them, says Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City and blogger for The Hospital Leader.
“As much as we might be held accountable for certain outcomes like readmissions, the reality is we can’t control them,” he says. “There are so many other factors out there that we don’t know about. Is the readmissions rate a good proxy for quality? We’ve seen evidence that it doesn’t relate very well to mortality rates.”8
Assessing blame can be a slippery slope, some experts say.
“My first message to my hospitalist colleagues—myself included—is to try to stop reacting as if this were about individual blame for the discharging hospitalist,” says Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies, who practices HM at Newton-Wellesley Hospital in Newton, Mass. “Certainly, that’s not how CMS views it. They are incentivizing hospitals and providers to improve systems of care and provide new and better types of continuing care.”
Dr. Boutwell
Dr. Boutwell, who is also an attending physician at Massachusetts General Hospital in Boston, sees the good in programs such as HRRP.
“[The program] has done a good job of mobilizing resources where previously very little attention had been given,” she says. “It aimed to catalyze investments in readmissions reduction, and that has occurred.”
Often, when hospitalists don’t do an “adequate job” of preparing their patients for discharges, including failures in communicating with outpatient providers, patients are in a catch-22.
“In many cases the PCP may tell the patient, ‘I don’t know enough about your case. I need you to go back to the hospital,’” Dr. Boutwell says. “That’s a big part of what we’re trying to avoid.”
Larry Beresford is a freelance writer in Alameda, Calif.