Unintended consequences: CMS’ readmissions program might be harming patients

November 28, 2017 in Education

Updated Nov. 27, 2017

At St. Elizabeth Medical Center in Utica, N.Y., the CMS’ Hospital Readmissions Reduction Program was an expensive wake-up call to hospital leaders that they needed to do a better job of preventing patients from making a U-turn after being discharged.

The hospital was hit with a $397,153 penalty in 2013, the first year the CMS issued penalties under the program, according to a data analysis by Leavitt Partners. The medical center’s revenue was $197 million that year.


Health policy experts say it’s time to assess how the readmissions penalty program is impacting outcomes overall.
“Without a doubt, the penalty program wakes you up and makes you look at” readmissions, said Dr. Eric Yoss, senior vice president of quality at Mohawk Valley Health System, which operates St. Elizabeth. “If you previously wanted to ignore it, you don’t anymore.”

The health system has set up several quality-improvement efforts to try to drive down readmission rates in response to the CMS program.

For example, all inpatients are now screened for risk factors that might signal they are vulnerable to a readmission. Those high-risk patients are set up with navigators, who call them after discharge to ensure they have a follow-up appointment with their primary-care provider. And if they don’t, the health system sets up a visit at one of its outpatient centers within 10 days after discharge.


The efforts have worked. The financial penalty at St. Elizabeth has dropped from 0.21% of net revenue in 2013 to 0.03% in 2018. The hospital’s penalty will be $52,003 in 2018, according to Leavitt Partners.

“It is driving us to avoid readmissions and there is a quality component to it as well,” Yoss said. “We should be doing this anyway.”

Overall, the penalty program, which was established under the Affordable Care Act, has effectively motivated hospitals to change wasteful care practices and better manage populations. Readmissions have fallen as hospitals respond to penalties that can dock up to 3% of their Medicare payments.

But the tactics hospitals have adopted to avoid a penalty might not always be in the best interest of patients. As hospitals reduced readmissions for heart failure patients, their mortality rates increased, according to a recent JAMA study.

Health policy experts have pointed to flaws in the study’s methodology, but say it’s an important insight into how the financial incentives from the readmissions program can influence hospital behavior, and not always for the better.

“This program has gotten hospitals to focus on readmissions and a lot less on everything else,” said Dr. Ashish Jha, a professor of health policy at the Harvard School of Public Health. “The big penalty for readmission rates has meant hospitals put less attention on reducing complications and on reducing mortality.”

To a degree, the CMS’ own math has placed a higher value on reducing readmissions than improving mortality rates. Under the Hospital Value-Based Purchasing program, high mortality numbers cost a hospital 0.2% of its Medicare payments, compared with a 3% hit under the readmissions penalty program, according to a February 2017 study in JAMA Cardiology.

“That doesn’t strike me as sensible,” Jha said.


Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine
Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine
Readmission rates also aren’t the best indicator of quality of care, argued Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. Some readmissions aren’t avoidable and some may be beyond the hospital’s control, especially since patient adherence to a treatment plan also has an impact. Physicians can’t always control if a patient actually picks up and takes their medication.

“I don’t think we have approached this measure with the nuance it probably entails,” Pronovost said. “It presents some signal about quality but there are some non-quality signals as well.”

In a statement in response to the JAMA study, the CMS said, it “continuously monitors the impact of the measures used in our programs, including input from peer-reviewed research and other sources. Studies like this are important inputs as we continuously assess our programs.”


Heart failure, which is the most common Medicare readmission, is an incredibly complex condition to treat. And for advanced heart failure patients, a readmission is sometimes unavoidable, said Jay Cyr, senior vice president of surgical services at UMass Memorial Medical Center in Worcester.

“These people are very sick—keeping them out of the hospital is a challenge, and sometimes we can’t do that despite our best efforts,” he said.

Given the challenges of caring for heart failure patients, it’s plausible that tactics hospitals adopt to avoid readmissions have a negative impact on patients’ survival rates, said Jason Hockenberry, an associate professor of health policy and management at Emory University who has studied the CMS readmissions program.

Hospitals “change care processes, and they change how they handle patients, which could lead to some fraction of the patient population having their life shortened,” Hockenberry said.

That’s not to say hospitals turn patients away if they need care, Hockenberry said. But interventions made to help patients avoid a readmission might influence whether or not they decide to return to the hospital or wait to get an appointment with their specialist. Low health literacy among patients might lead to difficulty both in understanding discharge instructions and compliance with subsequent self-care protocols, he said.

“We still don’t understand what these incentives are doing to care processes, and how they might be impacting patients,” he said. “Are they satisfied with their care? That is unclear at this point.”

The CMS also adopted the program across all acute-care hospitals without much insight or evidence into how it will impact hospitals. “We have no idea whether reducing readmissions is going to have an impact on health outcomes,” Hockenberry said.

Dr. Karen Joynt, an assistant professor of medicine at Washington University School of Medicine, rejected the notion that the CMS program might be having a negative impact on patient care. “It doesn’t kill people to try to improve the discharge process,” she said.

Even with the positive statistical results the program has shown in driving down readmissions, Johns Hopkins’ Pronovost said the JAMA study warrants more follow-up in terms of the broader impact on outcomes.

“There was a lot of good by increasing attention on care coordination and thinking about patients when they leave the hospital,” he said. “But now we have a signal that there are unintended consequences, so I think (policymakers and researchers) really need to come together and talk about why this might be happening and what should we be doing going forward with this measure.”

Correction: An earlier version of this story misnamed the Hospital Readmissions Reduction Program. This error has been corrected.

How kidney disease, peripheral artery disease, and amputation intersect

November 27, 2017 in Education

As the ninth leading cause of death in the United States, and a condition that affects an estimated 26 million Americans, chronic kidney disease is a growing health epidemic that creeps in silently, but can quickly manifest in deafening ways. While kidney disease is widely recognized and understood by patients, it’s equally as important to focus on related disease conditions.

Perhaps one of the most devastating impacts of CKD—and one we don’t hear about nearly enough—are complications associated with CKD and cardiovascular disease, particularly peripheral artery disease (PAD) and resulting limb amputation. Leading factors for both CKD and PAD are hypertension and diabetes, underscoring the multiple health risks patients face when diagnosed with these chronic conditions.

Research has further shown that Americans with CKD are at a higher risk than the general population of developing PAD, which causes narrowing or blockage of the vessels that carry blood from the heart to the legs. Poor circulation not only causes excruciating pain, but can lead to tissue death and complex, untreatable ulcers.

Vascular disease—including PAD—is now responsible for 80% of all amputations. Undergoing an amputation due to advanced PAD is both physically and emotionally devastating. It can be a source of lifelong pain, impact a patient’s quality of life, and the ability to work and function independently. Amputations also bring enormous costs to the health care system—an estimated $10.6 billion annually.

But the news for CKD patients with PAD isn’t all bad. Current technologies are available that can help reverse some of the most devastating symptoms. Outpatient interventions like angiography, revascularization (which restores critical blood flow to affected limbs), and atherectomy (a minimally invasive endovascular technique that removes plaque from blood vessels), have helped decrease the incidence of major amputations by 75%.

The benefits of this type of care can be nothing short of life-changing. With access to a PAD specialist and appropriate intervention, patients can enjoy reduced pain, enhanced mobility, improved quality of life, and a better outlook overall. In fact, the mortality rate for those who avoid amputation drops to just 16–24% compared to 48-71% for those who undergo an amputation.

This data underscores the need for public policies that increase access to PAD diagnosis and intervention, particularly among older Americans dependent on Medicare to access care, and who are often living with multiple comorbidities common across this population, including diabetes and hypertension. Other important factors impacting both CKD and PAD patient groups are the racial disparities that exist, which show African and Hispanic Americans are at a measurably higher risk for both diseases conditions.

For CKD patients diagnosed with PAD, the critical importance of appropriate and timely clinical intervention cannot be overstated. Unfortunately, there are a host of challenges affecting this population, including delayed vascular specialist referral, and slow PAD treatment initiation. Furthermore, studies have shown that patients with CKD are less likely to be provided recommended “optimal” PAD care.

Combatting the silent devastation that comes with CKD means educating Americans about their risk factors and working to provide the very best care possible to help avoid CKD’s most serious complications. Better access to PAD treatment to ensure limb preservation is central to this effort.

Glucose Variability Linked To CVD Risk

November 27, 2017 in Education

Minimizing glucose variability (GV) could improve insulin resistance and reduce the risk for cardiovascular disease (CVD) among patients with type 2 diabetes, according to a recent study.

For their systematic literature review, the researchers analyzed 22 studies with a total of 1143 patients with high GV and 1275 patients with low GV. These studies assessed all GV and CVD risk factors, which included total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), body mass index (BMI), waist circumference (WC), high-sensitivity C-reactive protein (Hs-CRP), homeostasis model assessment-insulin resistance (HOMA-IR), and carotid intima-media thickness (IMT).
Out of the CVD risk factors included in the analysis, the researchers found that HOMA-IR and reduced IMT were affected by GV. Patients with low GV had significantly lower HOMA-IR and IMT levels compared with those with high GV, but there was evidence of heterogeneity in the studies. However, there were no other significant statistical differences.

“Among these selected CVD risk factors in type 2 diabetes, minimizing GV could improve insulin resistance and reduced IMT, consistent with a lowering in risk of CVD.


Liang S, Yin H, Wei C, Xie L, He H. Glucose variability for cardiovascular risk factors in type 2 diabetes: a meta-analysis [published online November 14, 2017]. J Diabetes Metab Disord.