You’ve heard of evidence-based medicine, right? Evidence-based medicine (EBM) is the “good” medicine. Ideally these are things that clinicians do that have randomized, double-blind controlled trials behind them. Everything else, which is in reality almost everything, is the “bad” medicine. But don’t take our word for it. Here’s what President Obama said in a press briefing on July 22nd, 2010:
“Part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works…. Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that’s out there. … the doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out … I’d rather have that doctor making those decisions based on whether you really need your kid’s tonsils out, or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what’s best for patient care.”
To be perfectly fair, however, the President’s appointees have done plenty to undermine the administration’s supposed commitment to EBM. This happened first when Secretary of Health and Human Services Kathleen Sebelius initially embraced “evidence-based” recommendations that women in their 40s not undergo screening mammograms, only to scoff at the notion when the resulting political poo hit the fan.
It happened again with Dr. Donald Berwick, the Head of the Center for Medicare and Medicaid Services (CMS). Generally thought to be a staunch advocate for the use of EBM, he subsequently expressed allegiance to an alternative healthcare religion (we use this term somewhat tongue-in-cheek, since many of the positions taken by people on these sorts of issues often take on the characteristics of faith-based assertions rather than rational arguments when you look at the entirely of what’s being advocated), known as “patient centered medicine”. We’ll let Dr. Berwick explain in his own words, and refer the reader to an excellent post in the blog Science-Based Medicine for a good read of how schizophrenic our healthcare leaders can be with respect to the policies they’re recommending:
“First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.” I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she–the professional–disagrees with a patient’s choice. If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices–like lots and lots of patients’ choosing scientifically needless MRIs–then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch.”
So we already seem to have a disconnect between the rhetoric of the President of the United States and the thoughts and actions of his appointees. Since this blog seeks to illuminate the Road to Hellth, the next question is whether take things one step further into regulatory hypocrisy?
That’s where the news comes in handy.
As part of the “ObamaCare” Accountable Care Act, the nation’s largest insurer (Medicare) is implementing a program that doles out drastic financial punishments to hospitals that are found to have a higher-than-average percentage of patients with certain diagnoses (heart attack, heart failure and pneumonia ) who are re-admitted within a 30 day period. Rather than simply docking the hospitals for the cost of the re-admission, or even charging a penalty on the admissions for each of these diagnoses, the federal government will seek to claw back a portion of payments for all Medicare patients admitted with any diagnosis over the course of the entire year. The largest potential reduction for a hospital would be one percent in FY 2013; two percent in FY 2014; and three percent in FY 2015 and beyond, but even these small percentages can add up. The Health Care Advisory board looked into this:
“Our analysis indicates that around 3,100 acute care hospitals will be included in the readmissions program, with more than 2,300 expected to face some degree of reduced payment as a result of having “worse-than-average” readmission performance. Further, we found that 26% of hospitals are likely to not see any readmissions penalty in FY 2013, while nearly 60% will face payment reductions of between $10,000 and $500,000. Based on this data, we expect to experience an average penalty of around 0.30% of inpatient payments–approximately $88,000 per hospital.”
In other words, Medicare will be clawing back about over $200,000,000 from “deficient” hospitals in 2013. And while the penalty is based on having “above average” re-admission rates, 60% of hospitals will be tripped up by the rules. This is reminiscent of Lake Woebegone, except that the majority of Medicare’s children are slated to be below average.
Readers willing to explore the unknown can find the details of this exciting re-admissions penalty program buried deep in this Federal Register notice.
Based upon this “quality enhancement” program and the stiff penalties to be levied, it must be the case that most hospitals have lots of unjustifiable re-admissions, right? And if we’re after outliers, presumably there is great variability in the rate of preventable readmissions. Moreover, the government presumably constructed this program by using evidence-based criteria for these numbers of irresponsible re-admissions. But most importantly, it’s gotta be the case that being above- or below-average is mostly just a case of competent versus incompetent hospital care, or these penalties are just as likely to punish good hospitals as bad ones. If that’s the case, their only real impact will be to suck more money out of the private payment sector (which already heavily subsidizes Medicare and Medicaid) and put it into government coffers.
So what does federal government and its regulatory experts know about readmission rates that have allowed them to create a program this wise and this powerful? Well for one thing, readmissions are clearly the fault of the hospitals involved. The Medicare Payment Advisory Commission says so. In a June 2007 report, it said three-quarters of readmissions are “potentially preventable.” How do they know this? It’s easy. They simply modeled it using software created by 3M Corporation. What could go wrong with that?
“For the purposes of this analysis, we explored identifying potentially preventable readmissions with software developed by 3M (see text box, pp. 108–109). Potentially preventable readmissions are those that in many cases may be prevented with proven standards of care; however, not
all potentially preventable readmissions can be avoided, even if hospitals follow best practices.
We used the software to identify which of the readmissions were potentially preventable. The 7-day rate for potentially preventable readmissions is 5.2 percent, the 15-day rate is 8.8 percent, and the 30-day rate is 13.3 percent (Table 5-2). Accordingly, 84 percent of 7-day readmissions, 78 percent of 15-day readmissions, and 76 percent of 30-day readmissions were flagged as potentially preventable.
Medicare spending on these potentially preventable readmissions is substantial: $5 billion for cases readmitted within 7 days, $8 billion for cases readmitted within 15 days, and $12 billion for cases readmitted within 30 days.”
Were there studies of actual patients and hospitals behind these numbers? Nope. Instead, MedPAC used the 3M model to calculate the “expected” distribution of readmissions and compare it to the actual rate for the various hospitals throughout the land. Amazingly enough it found something like a pretty darned conventional bell curve when they looked at the distribution of hospitals and readmission risk. Here it is:
Note that there is a greater than 5% difference in the predicted readmission rate between the worst hospitals and those around the mean, and a greater than 10% difference between the best and worst hospitals. Based upon this information, MedPAC and Medicare concluded that there was a terrible problem with negligent hospitals providing inadequate care and operating a “revolving door” policy for readmissions. But what happens if we look at real data instead of the predictions of 3M’s computer model?
For one thing, we find that there is an astonishingly low amount of variation in readmission rates among the thousands of hospitals in the U.S. Let’s take one of Medicare’s penalty diagnoses, congestive heart failure (CHF) as an example.
In contrast to Medicare,Keenan, et al. actually bothered to look at the historical 30-day readmission rate for CHF patients in a retrospective study using Medicare claims data. This is the real-life distribution that they found:
In the real world, the mean adjusted readmission rate is 23.6%. For hospitals in the 5th percentile (i.e., the very best), the rate was 22.2%, while the readmission rate for 95th percentile (among the worst of the worst) was 25.1%. These are variations from the mean of only 1.4% and 1.5% respectively, about five times less than Medicare’s fabulous 3M computer model had predicted.
Just think about what this means for a moment. Consider a tale of two hospitals. One hospital is average, the second is, (according to Medicare), “terrible” with respect to its management of CHF – an outlier at the 95th percentile. Each will admits 100 patients with CHF this year. Statistically speaking, by the end of the year the “average” hospital will have readmitted 24 patients, while the “terrible” hospital will have readmitted 25. How on Earth could anyone distinguish the readmission results of these two hospitals from chance alone?
But there is, of course, more to this story. What about MedPAC’s computer model assessment that a whopping three-quarters of 30-day readmissions are “preventable”? How does that square with the available evidence?
Here too, others have done a far better job than Medicare in developing real-world benchmarks. (Even scarier, in this case the others are Canadian.) Carl van Walraven et al. at Ottawa Hospital Research Institute and elsewhere took a look at all urgent, unplanned readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals over a four year period. “Summaries of the readmissions were reviewed by at least four practicing physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided.” Their findings? Only 18% were deemed to have been avoidable.
Let’s look back at our two hypothetical hospitals each having 100 admissions for CHF. At the “average” hospital, 4.2 of their 24 readmissions could be considered to be “avoidable”. At the “terrible” hospital, 4.5 of 25 readmissions will have been avoidable. This amounts to a difference of one excess “preventable” readmission for every 330 CHF patients admitted – hardly a number that can be reliably distinguished from chance alone when looking at gross readmission rates. Given that there are far more “average” hospitals than bad ones, Medicare’s methodology will statistically, and inevitably, punish more good hospitals than bad ones.
In medical terms, it’s as if the majority of patients found to have a lump will be slated for chemotherapy, simply because it’s possible that they might have cancer. Would you rely on doctors who takes this approach? Would you trust them with your family? Would you trust them with running your healthcare system?
It appears that the Administration and the ACA are hardly practicing evidence-based medicine when they dictate hundreds of millions of dollars in penalties for an actual majority of hospitals treating Medicare patients. Based on our analysis of the data, we’ve taken the liberty of paraphrasing the quote that President Obama made at the beginning of this post. Wouldn’t it be refreshing to hear a politician make this speech?
“Part of what we want to do is to make sure that those decisions are being made by [bureaucrats and politicians] based on evidence, based on what works…. Right now, [bureaucrats and politicians] a lot of times are forced to make decisions based on the fee payment schedule that’s out there. … the [bureaucrats and politicians] may look at the reimbursement system and say to [themselves], ‘You know what? I [save] a lot more money if I [create a computer model that claims that hospitals are incompetent, and then make rules that generate stiff penalties for hospitals whether or not they're doing anything wrong] … I’d rather have that [bureaucrat] making those decisions based on whether you really [did waste money], or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what’s best for [everyone].”
Don’t hold your breath.
But who are these miscreants with such high readmission rates, and is it even cost-effective to reduce them? And what should hospitals do under these circumstances?
We’ll take a look at those questions in our next post.