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MI Penalties Linked to Severely Ill Patient Populations

DALLAS — Are hospitals that serve more minorities and sicker patients unfairly penalized by Medicare readmission penalties?

A new study published in JAMA Cardiology provides additional evidence to bolster the argument.

University of Texas (UT) Southwestern Medical Center-led researchers aim their fire at the Centers for Medicare and Medicaid Services' (CMS) Hospital Readmissions Reduction Program. It slashes payments by as much as 3% for hospitals that post high 30-day readmission rates for heart attack, heart failure, or pneumonia.

For this study, researchers focused on one-year outcomes for acute myocardial infarction (MI) patients at 377 hospitals. Hospitals cited for having an excessive readmission ration (ERR) had similar one-year mortality and long-term readmission rates as those whose readmission rates were considered acceptable, they found. Significantly, study authors emphasized, the hospitals hit with penalties also were more likely to have a higher census of minority patients and those with more severe illness.

"The current CMS readmission metric does not correlate with long-term clinical outcomes,” explained lead author Ambarish Pandey, MD, a cardiology fellow at UT Southwestern. “Furthermore, there is an inequitable distribution of the penalties such that hospitals that treat a greater proportion of socially or medically disadvantaged patients may be unfairly penalized despite comparable quality of care."

Focusing on results from the first cycle of the Hospital Readmissions Reduction Program between July 1, 2008, and June 30, 2011, researchers determined that the percentage of patients of black race and with comorbidities including heart failure and bleeding complications rose with higher ERR for myocardial infarction.

While some increase in one-year readmissions was detected among the hospitals with higher MI-ERR, study authors suggest most of those occurred early after discharge. No elevated risk for mortality was documented, however, within a year of discharge in either the overall or 30-day analyses.

Previous research by the same study team found similar issues with penalties for readmissions related to heart failure. Pandey suggested that the accumulation of evidence makes a strong case for re-evaluation of the readmissions reduction program.

"Our findings raise concern about the fair and equitable allocation of CMS penalties for readmissions,” added senior author James de Lemos, MD. “Hospitals that take care of larger numbers of patients with socioeconomic disadvantage, including a higher proportion of race and ethnic minorities, are more likely to be penalized, even though quality of care measures and long-term outcomes were not worse for these hospitals. It is fundamentally unfair to penalize hospitals for factors that are beyond their control.”

De Lemos recommended that those hospital characteristics be factored into the equations used by CMS to levy penalties.