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Not Returning as Often to Hospitals. Is That a Good Thing?

A new government program was supposed to prevent certain Medicare recipients from cycling in and out of hospitals. Now some experts worry it may be costing lives.

By Paula Span

It was a well-intended policy. Almost all parties agree on that much.

A decade ago, when Medicare beneficiaries were discharged from hospitals, one in five returned within a month.

Older people faced the risks of hospitalization all over again: infections, deconditioning, delirium, subsequent nursing home stays. And preventable readmissions were costing Medicare a bundle.

So the Affordable Care Act incorporated something called the Hospital Readmissions Reduction Program, which focused on three serious ailments with high readmission rates: heart failure, heart attacks and pneumonia.

The A.C.A. penalized hospitals — withholding up to three percent of Medicare payments — when readmissions within 30 days exceeded national averages.

The program, which took effect in 2012, seemed to work as intended. Within a few years, studies appeared in prestigious medical journals showing dramatic drops in readmissions.

“They declined the most in the hospitals doing the worst — just what you’d hope for,” said Dr. Robert Yeh, who studies cardiology outcomes at Beth Israel Deaconess Medical Center in Boston. “We thought, ‘Oh, looks like it’s been successful.’”

Now, it’s not so clear. Are readmissions for those conditions really dropping as substantially as it first appeared? Or has the program’s impact been overstated?

Are Medicare patients getting better care, or are they being kept out of hospitals to avoid readmission penalties? Are people getting hurt in the process?

There’s no consensus on the answers, as research has produced conflicting results. But the questions intensified recently as two new studies helped stoke skepticism.

One study, published in JAMA, reported that deaths from heart failure and pneumonia within 30 days of discharge have risen since the program began. “There’s a cloud over this,” said Dr. Yeh, the study’s senior author.

The readmissions program had no pilot testing before it began affecting decisions in thousands of hospitals, he noted: “Why couldn’t we have rolled this out in a way that let us evaluate it better?”

A spokeswoman for the Center Medicare and Medicaid Services, citing “deep concern” about findings of increased mortality, said in an email that the agency would thoroughly review both studies and their methodologies and conclusions “to inform any future actions.”

Reservations about the program’s claims to success, focusing on how hospitals report their statistics, had already surfaced before these latest studies.

To control for the fact that some patients are much sicker than others to begin with, Medicare uses “risk-adjusted” readmission statistics to prevent unfair penalties when higher-risk patients return to the hospital.

Those designing the new program expected hospitals to reduce readmissions by improving transitional care: giving discharged patients better instructions, following up with advice and referrals, perhaps providing home visits.

But a study of seven million Medicare hospitalizations suggested a more disappointing explanation. Looking at readmissions before the program, then after its announcement and implementation, the researchers noticed a distinct drop in a single month: January 2011.