NHPFlogo250Last Friday I was at a session of the National Health Policy Forum (NHPF) in Washington D.C. focused on Medicare's readmission reduction program The program, authorized under section 3025 of the Patient Protection and Affordable Care Act (PPACA), is the "stick" to section 3026's "carrot."

Section 3026 authorizes the $500 million Community-based Care Transitions Program that will pay partnerships of community-based organizations and hospitals to offer evidence-based, post-discharge services to reduce readmissions. Section 3025, in effect since October 2012, dropped the other shoe and requires the Centers for Medicare and Medicaid Services (CMS) to reduce payment for Medicare services to hospitals whose patients have higher than expected rates of rehospitalization within 30 days of discharge. (For more background, watch this Modern Health interview with longtime John A. Hartford Foundation grantee Eric Coleman, MD, read this recent Reuters article featuring Coleman, and this post I wrote on Health AGEna in December 2010.

Clearly the audience at the session was very concerned about the program and seemed sure that it should changed, if not abandoned (See my response to a Wall Street Journal op-ed last month.). I see the matter very differently and I'd like to explain why. NHPF Sessions are off the record, so I won't use any quotes or attribution.

First, I don't think that the banality of the typical readmission came across. The overwhelming tenor of the questions reflected an operating assumption that going to the hospital is good for people and the only way to meet an uncontrollable health crisis.

I think (re)hospitalizations are more likely to represent a poorly planned or executed discharge from a prior hospital stay and/or a failure of outpatient care. My prototypical readmissions story is not about how a hospital heroically saved someone's life, but how it risked the life of my colleague Rachael Watman's father by simply leaving a critical prescription drug off the discharge plan.

And lest you think this is unusual, watch this video of Laurie Robinson, RN, speaking at the CMS National Conference on Care Transitions kick-off meeting for PPACA section 3026 in December 2010. Mistakes with medications are among the most common and preventable causes of readmission.

The evidence is also very clear from the Care Transitions Intervention itself that with patient/family education delivered in one home visit and a few telephone calls, rates of readmission can be greatly reduced. Patients for whom those simple interactions can change the outcome are not people who really needed to go back to the hospital, but rather show how low-hanging the readmissions reduction fruit actually is. Similarly, readmission rates vary widely around the country. There are high-performing hospitals serving every demographic, region, and condition—demonstrating that better performance is not only possible, it's already being done, just not everywhere.

Second, the framing of this issue is around needy patients and struggling hospitals being denied services and payments, respectively. However, in the very same Forum room, I have heard hospital administrators admit that they could and should reduce readmissions, but that they can't and won't until the system stops paying for bad care.

Paradoxically, the audience did recognize the possibility of unethical profiteering—but only that driven by the readmissions reduction program. Many audience members were sincerely concerned that patients who looked like readmission risks might be denied admission in the first place in response to the new incentives. I don't think the balance of incentives and physician decision-making makes this plausible (this year's cut averages $125,000 for hospitals facing penalties).

But regardless, even if you do believe this argument, why aren't you afraid that hospitals are already doing sloppy work because they can benefit financially from their sloppiness? Why is only the new policy perceived as threatening to seduce physicians and hospitals into bad behavior? Isn't it just as possible that the old incentives already have? As Upton Sinclair put it, “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Finally and most frustrating to me, the readmissions penalties are often argued to be an unfair double whammy for hospitals serving low-income and otherwise disadvantaged populations. And indeed, the evidence is quite clear that low-income status does increase one's risk of being readmitted to the hospital.

But the hospital argument is essentially that they can't do anything about readmissions for their patients and shouldn't be expected to. I am sure that well-intended people can't mean to legitimize health disparities as inevitable, but that's what it sounds like.

If the weakness of social networks and personal and community resources makes patients likely to get sick again because they don't get their medicines or don't understand the instructions or can't get to outpatient follow-up appointments, I don't think the answer is just to keep rehospitalizing people and prop up a broken system.

Rather, the hospital and its staff have to leave their silo, work with their patients, and help develop resources in the community to help people stay well. Perhaps it is unfortunate that such a shift has to be motivated by a penalty, but the readmissions problem has been well documented for many years and we need some urgency.

Reform is a complex and scary task. For people who see the status quo of health care for older adults as acceptable, change may seem to be an unjustifiable risk. And indeed there are so many changes going on that it is hard to keep track — no one in the Forum session mentioned the resources being added to help hospitals and providers reduce readmission, either through the 3026 program or the still new and little-known outpatient care transitions payment added to the physician fee schedule for 2013.

But I think the evidence is very clear: Our current system does not deliver high-quality care to older adults with chronic illnesses and puts their lives and well-being at risk. It also costs beneficiaries and the treasury a great deal as it does so.