The Law of Unintended Consequences Strikes Hospital Patients

Have you ever heard of the law of unintended consequences? This is when something that was supposed to be beneficial turns out to bite you in the butt. Here is just one example: Kudzu is an ornamental Asian plant that was introduced into the U.S. in 1876. The U.S. government paid farmers to plant kudzu to reduce erosion. But kudzu has invaded Southeastern states and displaced native plants. It’s a mess to deal with. We have a new mess to contend with regarding the Hospital Readmissions Reduction Program (HRRP).

Unintended Consequences of the Hospital Readmissions Reduction Program (HRRP):

The Hospital Readmissions Reduction Program (HRRP) was supposed to cut readmissions for heart failure, heart attacks and pneumonia. The government, through its Centers for Medicaid & Medicare Services (CMS), wanted to encourage hospitals to keep patients long enough to improve chances of good recovery and prevent readmission.

There had been a trend to release patients quicker and sicker. It seemed to save hospitals money. If they were reimbursed primarily for procedures like appendectomies or heart stents, regardless of time in the hospital, they had quite an incentive to get patients out the door faster.

Did That Make Sense?

Here’s a crappy metaphor to try to explain the old system. Imagine you are being paid a set amount to fill potholes in your town or city. The local government reimburses you depending upon the size of each hole you fill. A six-inch-wide hole is reimbursed less than one that is five feet wide, but perhaps not quite as much as you would like. You might be tempted to fill the big, nasty potholes as fast as you could and not worry too much about how well the patches lasted.

Now imagine that the city figured out that you were not being diligent enough on the really hard-to-fix potholes. The administrators decided to punish you if your repair lasted only 30 days instead of a year or two. If you had to go back and repair a bad pothole patch within a month you would be penalized financially. You might have to pay back a lot of money if you didn’t do a good job.

The Hospital Readmissions Reduction Program (HRRP):

The Hospital Readmissions Reduction Program (HRRP) penalized hospitals financially if their readmission rates were too high. If a patient was discharged too soon and had to come back to the hospital within a month, then the hospital got dinged financially.

An editorial in JAMA (Dec. 25, 2018) described it this way.

“In fiscal year 2018, 80% of the hospitals subject to the HRRP have been penalized, amounting to $564 million in reduced payments by Medicare.”

That is a lot of money that hospitals had to give up. Not surprisingly, the program did indeed result in fewer hospital readmissions. Hospitals pay close attention to the bottom line. No surprises. The system seemed to be working. If you knew you would get dinged for bad pothole repair, you might be very careful to make sure the potholes lasted at least 30 days.

The Law of Unintended Consequences Strikes!

Research published in JAMA (Dec. 25, 2018) suggests that the Hospital Readmissions Reduction Program (HRRP) has actually resulted in increased mortality for patients with heart failure and pneumonia. That was not supposed to happen. Increased deaths were unintended consequences. Reducing premature discharge from the hospital should have improved survival. What went wrong?

Why Did the Hospital Readmissions Reduction Program (HRRP) Boomerang?

This gets very sticky. As already mentioned, hospitals pay attention to the bottom line. But their mission is to improve patient health. How do they reconcile these potentially contradictory goals?

The JAMA researchers noted:

“The increase in mortality for heart failure and pneumonia were driven mainly by patients who were not readmitted within 30 days of discharge.”

Think about that statement. We will return to it momentarily.

The authors also go on to say:

“Most concerning, however, is the possibility that the relationship between the HRRP and postdischarge mortality for heart failure and pneumonia is causal, indicating that the HRRP led to changes in quality of care that adversely affected patients. Financial incentives aimed at reducing readmissions were up to 10- to 15-fold greater under the HRRP than incentives to improve mortality through pay-for performance programs, and some hospitals may have focused more resources and efforts on reducing or avoiding readmissions than on prioritizing survival.” [emphasis ours]

We interpret that to mean that some hospitals were so worried about being penalized financially for readmitting sick patients that they worked hard to prevent these very ill people from being readmitted. We’re not sure how doctors bought into that program. It would have violated their Hippocratic Oath.

The researchers noted that the HRRP:

“may have pushed some physicians and institutions to increasingly treat patients who would have benefited from inpatient care in emergency departments or observation units, which could be consistent with the finding that increases in post discharge mortality for heart failure and pneumonia were entirely driven by patients who were not readmitted within 30 days of discharge.”

If the Hospital Readmissions Reduction Program (HRRP) truly led to increased mortality, then we could call this the law of unintended consequences at work! Whatever the reason, it is tragic. Hospitals should not release patients quicker and sicker. They should also promptly readmit patients who are seriously ill and not leave them in emergency departments or “observation units.” If some hospitals have consciously influenced health professionals not to readmit sick patients within 30 days of discharge, we find that outrageous.

What do you think? Share your own experience with hospitals in the comment section below.

JAMA, Dec. 25, 2018