The People's Perspective on Medicine

The Law of Unintended Consequences Strikes Hospital Patients

The Hospital Readmissions Reduction Program (HRRP) was supposed to save lives. But the law of unintended consequences struck. Why are patients dying faster?

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

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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I had surgery for a broken hip on Thanksgiving Day. The Hospitalist wanted to send me home on Saturday. With Social Service help I was able to make an appeal to Medicare for a longer stay. It was granted, and I got two more days of care, which was essential.

I just recently broke my ankle. It was repaired in same-day surgery, and I was sent home. My husband works full-time and was recently diagnosed with prostate cancer. We live in a rural community where 85% of the people who work need to commute to work. There are very limited services for people who cannot drive. There are no taxis and no buses. My husband took off 2 weeks from work but had to return to work. I was left at home lying in bed next to a commode. My family either works full-time or lives in other states. I was told to remain on 6 weeks bed rest. I fell out of bed twice while alone but was able to get back up with great difficulty as I was alone.

Our insurance will not pay for health care providers who, as a Master’s-degree trained nurse, I know are not worth paying. I have seen far too many people at home with health care providers who I found sitting on the couch in the living room watching “soaps.” It has been one helluva’ time. I needed at least a week in the hospital to deal with my injury as I also have left-sided scoliosis and severe ostearthritis.

I survived due to my own tenacity and my husband who helped day and night despite side effects from prostate cancer treatment. I remember as a new grad over 30 years ago that patients with fractures like mine were kept in the hospital until they could at least attend to bathroom needs. Bah, Humbug!

This is something that only affects seniors who are on Medicare. Not Medicaid. If under observation and are sent to skilled nursing Medicare will not pay and supplemental insurance will not either. The bill must be paid by you or your estate before you or heirs can file a complaint. I started printing complaint form and if was over 70 pages. I contacted all of my senators and legislatures and only one response. Said a bill was being co authored to stop this. Sadly it must not have been passed. Our local hospital said the review board for the hospital is in St Louis, so can not speak to a local hospital person about observed vs admitted. Sadly grandma is being pushed off the cliff. I saw it happen with my mother. Very quietly. Discharged too early.

No one wants to see some one they love die especially if they feel the death might have been prevented with more or better care.

No one has mentioned we might be prolonging death…. with some of the care we give. Given a choice some elderly people would prefer to die at home. This is why it is important that families discuss their end of life wishes so all know what is desired. It is not an easy discussion, but necessary.

Even with knowing.. I learned how difficult it is , emotionally, to stop treatment. I had that experience when my husband was put in the “shock” room at an ER. I knew he would not want to be revived. Fortunately I did not need to make the decision.

Sad situation…and getting worse. Let’s face it folks—-look at a hospital BILL after you are discharged and be BLOWN AWAY! We were charged $110 PER FINGER STICK for my 60-year-old husband as he has diabetes. CAN YOU IMAGINE THAT? There is absolutely NO way to justify $110 PER FINGER STICK to check blood sugar. And we know it only gets worse—MUCH WORSE—if you have any procedures or surgeries!

My mother, age 89, had COPD. She was admitted to the hospital twice within a month. The second time, her doctor did not want to send her home with the possibility of being re-admitted again. Mom had 24-hour home help, but the doctor said she must go to a nursing home to recover.

Mom would have none of that. She died.

With the hospitals skirting admission by placing Medicare patients in “observational status” not only do they avoid the penalty of re-admission but they get to pass the costs onto these seniors.

As an RN, BSN, who enjoyed a 38 year career I couldn’t wait to retire after Obamacare. It was a game changer. Why anyone thinks greater government involvement in healthcare is a good thing is short sighted. People need health care, they need insurance, but everyone should accept responsibility for their needs.

This is not an unintended consequence of the AHCA but one of the things that was forewarned about it. I spent close to an hour this morning writing a thoughtful, detailed explanation of my opinion about it, which mirrors other comments here, but mine was regretfully not published.

Pamela, it appears your thoughtful response was published. I am grateful that at age 40, a young woman counseled me on just minor changes to my diet for better health as I aged. Now at nearly 79, I have some health issues (scoliosis/osteoporosis) but I am very healthy and on no meds! Just a good diet, managing my weight, moderate exercise, and trying to keep a positive attitude–so important for our well-being, physical and emotional.

My biggest health problem: trying to keep my PCP and endocrinologist from bugging me about taking “bone-building drugs” with horror stories of dying as a bed-ridden invalid from a fall/hip fracture!

We could have the best healthcare system in the world but, sadly, instead we have the most expensive healthcare system. The U.S. always ranks at the top of the list for highest expenditure per person for healthcare, and far down the list for patient outcomes. There are many factors involved in these rankings but the essential fact remains that money and greed are the dominant factors. It will not change until we, the people, demand change.

My husband has been hospitalized numerous times since last April. It has taken everything I could do to keep things on the straight and narrow and get the care he needed. My knowledge as a former Critical Care RN was paramount in getting the care he required. Doctors and nurses hate dealing with informed patients/family. They know they can’t BS them. My knowledge of Medicare rules and regs as a former Hospital Consultant makes me a double threat. How can the average non-medical person make sense of any of it?

I agree with Jane. Too much money, too many pockets. But later, too much money in too few pockets.
Big “non–profit” hospitals buy up smaller community hospitals, then they sell the chain to BIG profit-making corporations. We are watching this slow motion destruction happen in my rural area. A corporation owned by a big time doctor/politician will be sweeping in all profits from these currently non-profit, community supported hospitals and associated med/surg businesses.
Local people are fighting back, but as, apparently, the ink was dry on the deal before they even knew it was happening, I expect to see the price of everything rise and the value of everything fall.
IMO, after a certain point, it’s all about money and ego, not the wish to do good in the world.

Just goes to show politician don’t care about people they don’t have to put up with this they have care that most of wish we had.Dont blame hospital.Yes both parties don’t give a dam about people there biggest care is getting reelected

I was admitted to the Hospital in April 2018 for observation due to pneumonia, fortunately I was then immediately admitted because of the severity of the pneumonia. My stay in the hospital was for 6 or 7 days with intense treatment followed by my release with Home Healthcare. If I had not been treated with IV antibiotics, steroids, and breathing treatments every four hours, I don’t think I would have had such positive results. It took me a month of just staying at home with more antibiotics, steroids, use of a nebulizer, Home Healthcare and assistance from friends in order to get healthy again.

As a volunteer to a chronic pain support group I have heard many statements about not determining the cause/s of the pain/s. Many following surgery, months later, are worst than before surgery. Unable to function as before recommended surgery. It is no wonder that those on some of the strongest opioids, wounder what action to take. What really caused a person on legal prescrib-ed opioids, to commi subside. The increased pain from surgery or the accidental overdose, or intentional overdose. Fortunately in the approximately 150 men and women I have met in person at our meetings, I have not witnessed, other than older age death of participants.

Our healthcare is a disaster in this country. So sad.
The bottom line is money, money, money.

i think he day they created a ‘HOSPITALIST’ meaning your doctor does not come to see younin hospital like they did in past years.This hospitalist MD only knows you from your chart-he/she has not known you petsonally–This has caued many mixups-since the MD only knows and treats the today problem.

I agree with Mary of Buffalo about these “hospitalists.” We encountered one at a local hospital who sent my 92 year-old father home with a broken hip. The doctor refused to have it x-rayed because that was not why my father was admitted. The second time I had to deal with him was six weeks later, when my mother was admitted with serious heart attack. She was told she would not live through this one. We wanted to bring her home to die, but he would not release her because he was afraid we would bring her back to the hospital. So, she died in the hospital instead of being at home with her family. This doctor “hospitalist” was the worst thing that happened to my parents.

Healthcare is first and foremost a lucrative business and you don’t believe that or forget it at your peril. The majority of doctors are little more than trained monkeys who learned only to apply cook book medicine and if you expect more you are not realistic.

If you believe your friend or family is being discharged when he or she ought to be admitted, do not accept it. Leave your friend or family member there – physically leave him or her (with an explanation to him or her as to why you are clearing out for a while). Do not make it easier for slovenly care. The red tail light sign is well known to health care providers. Use it.

In February 2018 I was admitted to a hospital late in the evening and stayed for a week. I had been in the ER for several hours. A roommate was admitted a little later. When we were talking during the week, she said that she had been in the ER area for 3 days. I couldn’t imagine that happening, but now I see there would be a reason.

It was the law of cause and effect, not unintended consequences.
These and other consequences may have been unintended according to those who passed the law but they were foreseen and warned of by the more realistic among lawmakers who bothered to understand its conceptual basis as well as details like this one, and opposed it. This was also a bill of thousands of pages that were dumped on lawmakers the night before its passage. They and the American people were told “You need to pass it to read it.” It was not legally funded, either. And now we’re only supposed to remember what mean people those who opposed it on substantive grounds were for “wanting to deny healthcare” to those in need.

I remember the days of relatively affordable health care and medicine (we have old bills!), when the poor could still obtain care if they chose, before all the bureaucrats muscled in to take their cut and the pharmaceutical lobby didn’t own Congress. AHCA was a bonanza for the lobbyist industries and those they bought off, wrapped in attractive language to make the sell and punish those who didn’t comply. There were problems before but not nearly as big or expensive as the ones that have been created by government intrusion.

Health care is not a Right, but it was never exclusively a privilege either. That is a myth. By demanding that government provide — and define — health care, we are asking for everything that comes with government –dense, bureaucratic rules and added costs, standardization of individual needs that defy standardization, and denial of rights to choose.

Here is one: There is an off-label, affordable treatment that is the only one available that has a high probability of allowing me to live a normal life, and I am not able to obtain it under my managed care government “insurance.” Medical massage would also help but is not covered, and neither are unaffordable supplements and healthy foods prescribed by non-insurance doctors. My travel, consultations with several doctors and extensive tests at Mayo Clinic were not covered by the “government” “health care.”
It’s called “government “instead of “public” now because those who pay for it or were providing free or affordable care to some of the poor don’t even get credit anymore. Those payers include myself, when I was able to work, and all of my family members their whole working and mostly healthy lives. The trip to Mayo was necessitated by the neglectful treatment I received under managed care, which refuses to co-pay and even makes it difficult to get its doctors to assimilate tests and diagnoses not received under its auspices. I will not get into other tremendous costs and problems other than to say that I have extensive experience with the good and the bad of insurance-ruled medical practice today. People need to educated themselves about it and draw their own conclusions instead of accepting everything they’re told at face value.

Another sad aspect of modern, pharma/government/lobbyist industry-created dependency, IMO, including lawyers and their lobbyists, is the way doctors who were previously willing to accept a few patients who could not afford care either for free or make financial arrangement for payment as able can no longer afford to risk the legal jeopardy that could come out of nowhere when ambitious trial lawyers get involved.

We are a wealthy, but also a bankrupt nation, nevertheless, no one wants to see people suffer, not Republicans or Democrats. The politicization and theft of our ability to receive the care of our choosing and in a way that is realistically affordable or catastrophically covered is a tragedy. Those who say they benefitted in the short term were encouraged to not understand its unsustainability and the ugly underside of the AHCA such as is noted in this article. What has changed for the poor who cannot afford care from what they were able to obtain before the authoritarian imposition of the AHCA can be debated. I personally believe one needs to look at the bigger picture of what passes for “food” nowadays in grocery stores and other factors affecting our health and infecting our politics.

Pamela, your thoughtful statement that you spent so much time writing is full of incorrect statements. Everyone could NOT receive health insurance prior to the Affordable Care Act. For example, insurance companies legally refused to write policies for individuals who had received a cancer diagnosis within five years. Therefore, a job loss for a cancer patient meant not only the loss of income but a possible death sentence and almost certain bankruptcy, because you had to first divest yourself of assets such as a home before being eligible for Medicaid for the poor. Please don’t simply berate a program that you obviously don’t understand without knowing the facts. Does it need some changes? Of course. Has it saved and improved lives? Definitely.

Possible explanations: patients needing admission were denied in the first instance just to avoid possibility of readmission. And patients needing readmission were sent home. Patients kept longer contracted pneumonia from lying around in germy hospital and not exercising. Same for heart issue. Just practice medicine. Administrators, pharma, device&equipment makers, and insurance should learn to manage costs without affecting treatment decisions. Can be done.

Both my father (93) & mother in law (96) would have lived a little longer & had much less horrific & traumatic deaths had this rule not been in place.

So, doctors do still have to take the hippocratic oath??? I was beginning to wonder. Perhaps the CEO’s of big pharma should have to take the same oath and suffer huge consequences if they violate it. Nah… too much money lining too many pockets.

As an older potential hospital patient, your article on HRRP scares the hell out
of me! Of course, their bottom line is important, but if they’ve stopped putting people’s lives first, we’re all in trouble!

I retired from a healthcare career after 42 years. A “nonprofit” organization. More and more as the years went by, I definitely felt their bottom line was their top priority. I had good managers just above me, but it was apparent they were being pressured about money, money, money in the later years. It felt like patients and employees were third and fourth in importance to the top people running the organization. Making money and looking good to the public were top on their list. They spent a lot of money to have not just good facilities, but exceptionally beautiful ones. And they donated a lot of money to get sports arenas named after them.

My husband has strokes, after the first he could walk, after the second he was in the hospital for two nights and readmitted but learned to walk with a cane, after the third only one night and much damage was done. He could no longer walk or care for himself and blindness in half of each eye, He was a healthy person with no health problems. I have to have caretakers all of his waking hours. Also he was in a nursing home after the third as a private patient. After the fourth I insisted he stay the required days for inpatient rehab. I have no faith in our system anymore and the drug prices are way too high. Its all about greed, not healthcare.
His therapy was not the best and I wasn’t given information as to what he needed. I had to search the internet and figure it out myself. A wheelchair was provided.

On 12/5/17 I took my husband to the ER due to a fall and fever. He was diagnosed with pneumonia and sent home with antibiotics. Two days later his pcp sent him back to the hospital for admission. He died on 12/11/17. I believe if he had been admitted the first time he would still be alive today.

Amen to that

JACKIE. I am so sorry to hear about your husband’s passing. I agree with you. I feel it is the bottom line. MONEY. Jackie you take care.

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