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White Coat Notes

Hospital penalty plan is faulted

Excerpted from the Globe’s health care blog.

They have been warning for months that the readmissions measure is faulty.

In April, doctors Karen Joynt and Ashish Jha wrote in the New England Journal of Medicine that the federal policy of penalizing hospitals where patients are more often rehospitalized within 30 days was misguided, unfairly targeting those in poor areas with large minority populations.

In a research letter published Tuesday by the Journal of the American Medical Association, the researchers, who are from the Harvard School of Public Health, added some heft to their argument. They looked at penalties assessed against 2,189 hospitals and found that the largest hospitals and those that are teaching hospitals or safety net hospitals, meaning they care for the highest portion of poor patients, were most likely to have their payments docked.


Forty percent of large hospitals and 44 percent of major teaching hospitals received the highest penalties, compared with 28 percent of small hospitals and 33 percent of nonteaching hospitals. Forty-four percent of safety net hospitals were highly penalized, versus 30 percent of those without such a designation.

Joynt said the mathematical models used to predict which patients will have to return to the hospital soon after discharge are not very good — “barely better than a coin flip.” Those models are used to assess penalties by measuring how hospitals are doing, against what is expected of them.

They don’t fully account for the difference in severity of illness between patients at community hospitals and at those hospitals to which the sickest patients are referred, Joynt said. And they don’t factor in variables in patients’ lives once they leave the hospital grounds.

The likelihood of a person returning to the hospital after a heart attack depends a lot on housing, financial stability, and other socioeconomic factors, she said.


Joynt offered this example: One man has a stent implanted at Boston Medical Center after a heart attack. Another has the same procedure at Newton-Wellesley. But the first is homeless, and the second has a strong family support system, with relatives checking on him regularly to make sure he is taking his medications and has what he needs.

Of course, those men are not representative of all of the patients at those two facilities, but a homeless man may be a rare patient in Newton and a far more common one at Boston Medical.

The penalty program, created under the Affordable Care Act, is well underway.

The Centers for Medicare & Medicaid Services calculates penalties based on how many Medicare patients treated for certain conditions — pneumonia and heart attack, for instance — are rehospitalized within 30 days.

Hospital leaders and even some policy makers who worked to implement the program have called for changes.

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