Health Bill’s Hospital Readmissions Rule Could Lead to Rationing of Care, Say Some Patient Advocates

By Matt Cover | October 28, 2009 | 2:19 PM EDT

Sen. Max Baucus, D-Mont., successfully steered his health care reform bill through the Senate Finance Committee on Tuesday, Oct. 13, 2009. (AP Photo/Alex Brandon)

( – For Medicare patients, the details of congressional Democrats’ plans to try to curb preventable readmissions to hospitals – details the Obama administration would write – could mean the difference between better quality health care and the rationing of care, according to some patient advocates, analysts and members of Congress.
The plan, included in each of the five health care bills currently before Congress, attempts to curb preventable hospital readmissions by penalizing hospitals.
Hospitals with a higher-than-expected rate of readmission for eight as yet unnamed conditions would suffer penalties, for example, if patients had to be readmitted within seven to 15 days, according to the plan released by the Senate Finance Committee. The penalties would apply only for those readmissions involving Medicare patients.
According to the New England Journal of Medicine for Apr. 2, 2009, “as many as a fifth of all Medicare patients are readmitted within a month of being discharged … and a third are rehospitalized within 90 days.” The study in the Journal estimated “that the cost to Medicare of unplanned rehospitalizations in 2004 [the year studied] was $17.4 billion,” out of $102.6 billion in Medicare payments to hospitals for that year.
Back in July, when he was still alive, Sen. Ted Kennedy (D-Mass.) wrote in Newsweek that, “Most of these readmissions are unnecessary, but we don't reward hospitals and doctors for preventing them. By changing that, we'll save billions of dollars while improving the quality of care for patients.”
However, the details of the Democrats’ plan will not be written by Congress if the health bill becomes law. They will be written by the Obama administration in the Department of Health and Human Services (HHS), which will determine what medical conditions are covered and why.
Those details could result in better health care for seniors if the government gets them right. But if the government does not get the details right, it could lead to worse care or rationed care, according to health care experts.
Betsy McCaughey, former lieutenant governor of New York and a patient advocate with the Committee to Reduce Infection Deaths, where she is founder and chairman, told that, for patients, what matters are the still unwritten details of the Democrats’ plan.
McCaughey, whose group has campaigned in the past for penalties to try to reduce preventable infections in hospitals, said that financial penalties may be appropriate but that they could hurt patients if not structured correctly.
“In some circumstances, financial penalties against hospitals for avoidable costs are appropriate,” said McCaughey. “[But] in this case, the devil is in the details. It appears as if this provision could be very harmful to patients with chronic illnesses like heart disease because readmissions are not always avoidable.”
“[H]eart disease, which is the largest killer in the United States, would be on the top of the list,” said McCaughey. “We need to see the details. They should not be delegated to the Secretary of Health and Human Services because delegating them is a license for deadly rationing.”
Dr. Eric Siegal, a critical care physician at the University of Wisconsin and the chairman of the Society of Hospital Medicine’s public policy committee, said the proof of whether Democrats’ plans succeed will be “in the pudding.”
“There is no payment system that cannot be manipulated to the advantage of the providers and to the disadvantage of the patients -- there is no payment system that’s perfect,” he said. “The proof is going to be in the pudding.”
Dr. Siegal said that the question for health care reformers was how to create incentives that result in exactly the right behavior and which are not subject to manipulation or abuse.
“The question that we all struggle with in [Medicare] payment reform is how do you create a set of incentives that will reward exactly the right behavior?” he said. “There will always be people out there who will figure out ways of gaming it.”
Dr. Siegal pointed out that while negative consequences were inevitable, he felt that the overall effort was a positive one that attempted to solve a complex and costly problem.
“I think the general thrust of this is positive,” he said. “Will there be negative connotations? Sure. Will there be misapplications of this and people who game it? Absolutely, human beings are human beings and we won’t know until it actually gets implemented [but] I think the concept underpinning it is in response to a real and growing problem.”
McCaughey was less optimistic, arguing that Congress’ hands-off approach could end up hurting patients if HHS makes the policy too broad or applies the penalties unfairly.
“All of the decisions are delegated to the Secretary of Health and Human Services,” McCaughey said. “So it’s quite possible that readmissions could be penalized solely on volume rather than on [specific] medical conditions and that choices will be made to penalize hospitals for readmissions that are often associated with the elderly and chronically ill and are unavoidable.”
Rep. Mike Pence (R-Ind.) described the policy as one way congressional Democrats were paying for health care reform, by putting the burden on older Americans. "What's going on here by the Democrat majorities in Congress and the administration is simply paying for a government takeover of health care on the backs of seniors,” he told
Rep. Dave Camp (R-Mich.) said he agreed that the lack of detailed proposals meant that the policy might inadvertently restrict or ration seniors' care, by preventing them from being readmitted incorrectly.
“The short answer is yes, that is a concern,” Camp said. “Clearly, by giving so much authority to the Health Choices Commissioner [who would fill in the details under the House Bill], I think it runs the risk of ending up with policies that make it very difficult for the American people."
"Clearly, if you penalize hospitals for readmission rates, and many hospitals in Michigan and around the country are struggling to keep their doors open, we need to make sure that that policy is done right,” said Camp.
Patsy Drain, a former director of the Virginia Department of Human Resources, said that readmission decisions should be made by seniors and their doctors, adding that government regulations and penalties might inadvertently “doom” seniors to inferior care or even death.
“I think that decision ought to be made by my doctor and me,” she said. “I hate to say this but it almost sounds as if the decision is made that, ‘Oh, we can't readmit this person’ in the respect that you might be dooming that individual to even more serious health problems, for lack of attention, or even death itself."
Any negative effects of the plan would most certainly have political repercussions as well, according to Ethics and Public Policy Center fellow James Capretta, who told that if the Democrats’ plans cause too much pain, Congress will almost surely roll them back later.
“Whenever the government tries to make a hard and fast rule, the 10 or 20 percent of cases where it really isn’t well-suited to apply become the story,” said Capretta. “So maybe in general this is a good policy. But if you write a rule that is hard and fast that way, you’re going to end up with lots of stories of people who should have been readmitted [but weren’t].”
Capretta said those types of stories would likely cause Congress to roll back some of the penalties because of political pressure.
“The federal government has a very difficult time enforcing these kinds of rules on a sustained basis because there are inevitably going to be cases where the rules aren’t appropriate and run afoul of actual quality patient care,” he said.  “Then the government tries to backtrack and they end up undoing part of the rule and it gets watered down over time.”