Flaws in the Readmission Improvement Claims

Health policies are not created in a vacuum. There are changes from one policy design to the next that are important to understand. Changes in policies often result in what is seen regarding the positive and negative consequences of health policies. Areas such as readmissions may seem to be improving, but actually may be the result of a change as compared to previous policies that had readmissions problems - such as DRGs.

It is also important to understand that there are no health policy changes that are all positive although it is possible to result in changes that are all negative. Short term benefits may turn sour when viewed over the long term. Small impact areas may fail when viewed from the overall lens of health care cost or cost to a nation inside and outside of health care. 

Health policy changes result in winners and losers. 
Who wins and who loses is often a matter of perspective. 

Perhaps the most consistent finding is that those making the designs and those most closely associated with them are the ones who usually win the most. Those "outside," least organized, most distant, and least powerful are the ones who lose. 

Those most closely related to the designers (health policy researchers) typically find the way across proposals, legislation, reconciliation, and regulation to preserve the positive impacts for "their kind."  Insiders can generate the information, support the research, and pay for the promotion of insider information.

Not surprisingly the consequences for those outside, least organized, most distant, and least powerful are not seen - except perhaps in surprising election results. 

What is not seen is what is "outside." What is interesting as more promote quality improvement in medicine is that Deming and other quality experts have long promoted the importance of seeing the outside perspective. Few in health care have demonstrated this ability. 

Those who want to appear to be insiders often claim to have the outside perspective, but their work does not support such claims. Even worse are policies that are promoted as solutions, but act against the intent of their very title (No Child Left Behind, Race to the Top, Value Based Efforts that massively increase costs without improvements in outcomes).

Those shaped by decades of life experiences exclusive and inside are blinded to those outside - such as most Americans falling behind. Without different life experiences, there is low potential for a change that will result in positive gains for those in most need of such gains.

Recent events have forced Americans to deal with fake research and fake news, but much of what is accepted in health care research is flawed or is irrelevant for most Americans.

Fake news or published research can cause the same damage when those who encourage, support, and promote are lacking in objective critique.

Readmission improvement claims are a great example of the above.

Studies have been published indicating improvements in readmissions. On the surface these tend to indicate that the more recent policy changes from Obamacare are responsible. But outcomes should be examined in the context of the previous policies. 

It is relatively easy to see that readmissions improvements were made possible by the change from the previous policies. The change from DRG to ACA did add accountability but also indicates decades of adverse impacts from DRG and PPS payments. 

Some small measure of accountability can result in apparent accountability 
when accountability has been destroyed by previous policy design.

The Era of Cost Cutting Takes Over 

The 1980s were a time of major change. Previous designs supported delivery team members. The 1980s designs took over and cost cutting became the major focus - often without regard to consequences to team members and those most needed for areas such as basic access to care.

Health care rebuilding from 1965 to 1980 was important, but became more costly as those doing well found more ways to do well. It took some time for those opposed to Medicare and Medicaid (organized medicine) to recover from their failure to block this legislation. Not surprisingly they adapted well to maintain a major role in the medical-industrial complex. 

Those who did not fare well in the era of cost cutting include nursing, small health care, and care where needed.

The initial CMS design was more focused upon access and payments via health services for poor and elderly patients. The payments specific to poor and elderly impacted places that went from no payment to payment where concentrations of poor and elderly patients were found - rural, less concentrated urban, underserved.

Unfortunately the health services added over time were more costly and were more easily abused than the basic office codes and basic hospital services. This resulted in pressures to rein in costs. 

Instead of preserving important areas such as basic services and health access - cuts were made across the board. Instead of carefully tested designs - rapid chaotic changes were made such as seen in PPS and DRG payments. Not surprisingly small, rural, and basic services suffered. 

Access to care tends to suffer the most as local workforce is compromised where most needed. Thousands of hospitals were challenged by rapid change and lower payments and hundreds closed across the 1980s and 1990s. Of course this was a time period with little concern for the apparent impact of financial compromise upon care.

Designs that marginalized those who deliver the care have consequences. 

  • Nurses were hit the most by DRGs - easily predicted from a design that results in the need to reduce cost of delivery and send patients home as fast as possible. 
  • Health care is about the people to deliver care and nurses are the most costly personnel item. 
  • Lower nurse ratios are associated with lesser care although this is hard to separate from lower payment, more complex patients, or other factors.
  • Marginalized care during admission and rapid discharge are the obvious result of DRGs - and increases in readmissions are an obvious side effect.

Flash Forward to the Widely Promoted Readmissions Improvements

A comparison with the changes from Obamacare is important to understand. The pre-existing DRG payment resulted in incredible pressures to discharge too rapid plus marginalization of the personnel to deliver care.  The fact that these changes were in violation of the PPS "guidelines" is barely noticed.

Recent accountability is far too late after 30 yrs of DRGs - designs that cannot help but result in higher readmissions. 

Even worse,

  • What could possible happen with the combination of untested experimentation exceeding protective guidelines with little critical study? 
Some cry out for payment innovators to be held to the same standards as other human subject researchers, but there is no such accountability. Thus we continue to have combinations of untested experimentation with variable definitions of what is being done and often missing important controls - while still exceeding ethical and moral guidelines since protective guidelines have never been enforced. What could go wrong with Fire, Aim, Ready?

Where Is the Scientific Community

Readmission penalties are influenced by far too many patient, community, and other factors - as seen in penalties highest for lowest physician concentration counties (14%) with 9% for rural and 3% for urban. There is a consistent relationship for single county hospital readmission rates using smoking, preventable deaths, median income, college educated, obesity rates.

Discrimination via pay for performance is found in a dozen studies but this has not stopped CMS from doubling down on P4P as seen in MIPS to MACRA (Kip Sullivan). This has added a sixth degree of discrimination in payment design most impacting 2621 lowest physician concentration counties, those lowest in the variables that most shape outcomes.

Does anyone even understand the basic apples to oranges comparison flaw across hospital, male to female physicians, PCMH, and other comparisons given numerous and significant differences?

Does anyone understand how the or how the hundreds of billions now spent in pursuit of quality worship does little for outcomes and actually decreases value in the health system that is least devoted to value?

Pay for Performance has failed to deliver on promised outcomes, has driven up the cost of delivery, has added distractions for team members, has distorted health services research, and has contributed to two forms of discrimination with regard to most needed providers. It is time for something else such as returning the focus to support for the team members that deliver the care.

Demographics Against the Democrats

Not Easy Being Swiss Cheesy in Health Info Tech

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.


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