We the Patients

Medicare hospital penalties shed light on the concept of “social determinants” of health

Here’s something a lot of New Yorkers (and likely a lot of Americans) don’t know: Medicare penalizes your hospital if you have to come back too soon.

It makes sense if you think about it: ideally, after you visit a hospital, you shouldn’t have to come back any time soon (if at all). If you do have to return—and not for routine follow-up, that is, but actually have to be readmitted within a month of your initial visit—there’s a chance the hospital didn’t do something right in the first place.

That’s the operating premise of the Hospital Readmissions Reduction Program, first enacted in 2012 as part of Affordable Care Act. Per the program, every year hospitals are assessed for “excess readmissions” for three conditions: heart failure, acute myocardial infarction (heart attack), and pneumonia. If a lot of patients with those conditions get readmitted in fewer than 30 days, the Center for Medicare & Medicaid Services (aka CMS) withholds some of the hospital’s funding in the next year. The conditions were chosen because it is common for patients to get readmitted for those conditions – but in many cases those readmissions are preventable with quality aftercare.  Infection rates—i.e. infections a patient gets while staying in the hospital—are also taken into account as a part of the penalty assessment.

There’s evidence that program has succeeded in one way: hospitals have begun to pay more attention to their readmission rates and work towards improvement. However, several years in, the hospitals with the highest penalties have been those serving a larger percentage of low-income patients, aka “safety net hospitals.” Hospital administrators argue that those higher readmission rates aren’t the result of low-quality care but happen because their patients have fewer resources outside the hospital —i.e. lower-income patients simply didn’t have many of the resources that enable wealthier populations to avoid rapid readmission (e.g. medication, transportation to and from doctor follow-up visits, dietary stability, adequate housing, paid caregivers, etc.).

In 2018 a change was made: hospitals would be split into five “peer groups” and compared to other hospitals with similar patient populations instead of all hospitals for the purpose of readmission penalties. And on health disparities, that leaves us back to the drawing board. If New York doesn’t start taking the social determinants of health seriously, the central problem—sick poor people staying poor and sick—isn’t likely to improve anytime soon.

You can search for your New York State hospital on the most recent list of penalized hospitals here.

(Hospitals are assessed for readmission and infection rates from the year prior but penalties are applied in the following fiscal year, starting October 1st, 2019 through September 30th, 2020).