Thursday, January 29, 2015

Lynne: Initial CMS Evaluations of Readmissions Have Serious Flaws

Joanne Lynn M.D., Director of the Center for Elder Care and Advanced Illness at Altarum Institute, wields a scalpel and a battle axe in her recent criticism of initial CMS evaluations of readmissions. The lede:

The Centers for Medicare and Medicaid Services (CMS) has quietly put out two evaluations of the readmissions work– and both documents are remarkable for their failure to evaluate the programs fairly or to provide insights as to what works in what circumstances.


The readmissions/discharges metric that CMS and its evaluators use for categorizing success or failure is seriously flawed.  There is no reason why a 20% reduction in the now thoroughly discredited readmissions/discharges ratio is the best target. A more informative target would clearly focus on providing a reliable, well-characterized set of services that work to the advantage of patients and families and that also reduces total costs.

Much of the problem with the measures probably has roots in national leadership still conceptualizing the transitions work as being dominantly the responsibility of hospitals and their staffs, while people living with serious chronic conditions need a more comprehensive, community-anchored, population-based approach. Even so, responsible evaluation would require, at the very least, a close examination of actual numerators and denominators in order to interpret the simplistic and routinely misleading ratio. 

The most important issue is whether the CCTP (Community-Based Care Transitions Program) program is helping to improve transitions and keeping people who are living with fragile health in a more stable condition while living in the community, thereby reducing hospitalization. It would be easy for the evaluation to show that the supplemental services are desirable. Evaluators could test whether enrolled patients had many fewer medication errors, many more patients and families confident in their self-care, many more social services in place, and much more medical support in the community. However, the current evaluation does not address these points.

These first forays into evaluation of the readmissions work are quite disappointing. There are contractors and participants who know much more, and there are evaluation methods that would be much more revealing. The work on care transitions has been a powerful catalyst toward more comprehensive care planning and service support for people living with fragile health. It is time to push CMS and PCORI and any other funding agency, contractor, or grantee to do the work that informs managers and policymakers about what to do next, given what we’ve learned in the work so far.

1 comment:

Joanne Roberts, MD, MHA said...

As a hospital CMO, I recognize the many problems of the CMS readmission metric. Logically, it is unfair to put the onus of responsibility on acute care hospitals, just small part of a long life journey of a patient.

As a citizen and taxpayer, however, I ask, why should we not place the onus on the largest sector of healthcare? In 2015, most capital resources in the healthcare delivery sector remain in hospitals.

Of course, the unintended consequence is precisely what we are seeing: hospital systems purchasing physician practices in order to build integration -- a trend we saw in the 1990s.

The long-term consequence -- a few very large integrated healthcare systems -- may be good for the country, but the ride between here and there will be bumpy.

Joanne Roberts, MD