How Much Control Do Hospitals Have Over Readmissions?

The Centers for Medicare and Medicaid Services (CMS) has launched another attack on the problem of the nation's appalling readmission rate--about 20 percent of all Medicare discharges--by posting the readmission rates of hospitals that report data to the agency on its Hospital Compare website. More than 4,000 hospitals, including most acute-care facilities, voluntarily submit quality information to CMS.

Besides listing the percentage of readmissions within 30 days for heart attack, heart failure, and pneumonia, Hospital Compare now slots hospitals into one of three categories: no different than the U.S. national rate, or better or worse than that rate. Visitors can also compare a hospital's readmission rate to its state's average.

New York hospitals performed worse than the national average, and some hospital executives complained that CMS had not taken socioeconomic factors into account. But some community hospitals that serve unusually poor populations had lower readmission rates than New York academic medical centers did.

The Baylor Heart & Vascular Institute in Dallas had the lowest readmission rate for heart patients in the country, 15.9 percent. That is head and shoulders above the rest of the field. One reason for the hospital's excellence is its unusual persistence in follow-up care after patients are discharged. But most hospitals lack financial incentives to do follow-up--although that might change if Medicare "bundles" payments for inpatient and post-acute care.

It's not clear how much of the blame for readmissions can be laid at hospitals' doors. The same New England Journal of Medicine study that found one in five discharges resulted in readmissions also said half of the nonsurgical patients readmitted within a month had not seen a doctor for follow-up care. There's also evidence that patients often have trouble getting timely appointments with a doctor after leaving the hospital.

While hospital employment of primary-care physicians is rising, the majority of patients still depend on doctors in private practice for their outpatient care. Until there's better coordination between hospitals and community physicians, and between primary-care doctors and specialists, the readmission rate is likely to remain high.