Thursday, August 27, 2015
Health Affairs Blog
August 27, 2015
Quality Improvement: 'Become Good At Cheating And You Never Need To
Become Good At Anything Else'
By David Himmelstein and Steffie Woolhandler
The Centers for Medicare and Medicaid Services (CMS) has trumpeted the
recent drop in hospital readmissions among Medicare patients as a major
advance for patient safety. But lost amidst the celebration is the fact
that hospitals are increasingly "observing" patients (or treating
returning patients in the emergency department) rather than
"readmitting" them. But while re-labeling helps hospitals meet CMS'
quality standards (and avoid costly fines), it probably signals little
real quality gain and often leaves patients worse off financially.
In most cases, observation patients receive care in a regular inpatient
unit, and get treated just like other inpatients. And in many cases,
observation stays stretch out to several days: in 2012, 26 percent
lasted two nights and 11 percent at least three. But from Medicare's
point of view, this is outpatient care, which leaves patients
responsible for more of the bill, and ineligible for Medicare-paid rehab
or skilled nursing care.
Hospitals started designating more stays as "observation" after
Medicare's auditors began disallowing the entire payment for some brief
hospital "admissions." Even though "observation stays" pay less than
inpatient admissions, hospitals took a better safe than sorry approach,
classifying many brief stays as "observation." Between 2006 and 2013,
observation stays increased by 96 percent, accounting for more than half
of the apparent decline in total Medicare admissions during that
Medicare's recent adoption of penalties for readmissions offered
hospitals a new incentive to shift some patients returning within 30
days of their discharge to observation status. A patient stay labeled
"observation" doesn't count as a readmission, allowing hospitals that
might otherwise be fined for having too many readmissions to skirt the
About 10 percent of all hospital stays occurring within 30 days of
discharge are now classified as "observation;" a quarter of hospitals
classified 14.3 percent or more of all repeat stays as "observation."
Moreover, analysis of time trends in observation stays makes it clear
that they account for a significant chunk of the reduction in
readmissions. Between 2010 and 2013, 36 percent of the claimed decrease
in readmissions was actually just a shift to observation stays.
Emergency Department Use
And it's not just observation stays that have been on the increase. More
of the recently discharged patients are being treated in emergency
departments (EDs) — without being admitted — as well.
Factoring in the 0.4 percent increase in ED visits within 30 days of
discharge, the fall in the percent of discharged patients returning to
hospitals for urgent problems is only 0.3 percent over the past three
years — less than one-third of the improvement that CMS claims. And even
this 0.3 percent overall fall may be partly an artifact of hospitals'
"upcoding" (exaggerating the severity of patients' illnesses), which
boosts diagnosis-related group (DRG) payments, and could also corrupt
the formula used to risk-adjust expected readmission rates.
Medicare's readmission penalties are among the growing number of
pay-for-performance (P4P) and value-based purchasing initiatives that
offer bonuses to high performers and/or penalize the laggards. We
previously pointed out that the evidence for this carrot and stick
approach is unconvincing. More recently, a long-term follow-up of the
English hospital P4P program found that P4P generated no improvement in
patient outcomes, damping the enthusiasm generated by the rosy
short-term findings, and reinforcing the need for skepticism.
Adopting unproven everywhere P4P strategies that have been proven
nowhere risks quality failure on a monumental scale. It pressures
hospitals to cheat, saps doctors' and nurses' intrinsic motivation to do
good work even when no one is looking, and corrupts the data vital for
As the graffiti artist Banksy once said: "Become good at cheating and
you never need to become good at anything else."
Comment by Don McCanne
In lieu of adopting comprehensive health car financing that actually
would improve value - a single payer system - our national leaders have
elected to continue with our current dysfunctional system and try to
make it work. One measure that has been introduced is the assessment of
penalties for patients who are readmitted within 30 days of being
discharged from a hospital - on the theory that the patients should be
fully stabilized at discharge with followup arranged that would prevent
the need for readmission.
Physician and hospital administrators do not want patients readmitted
soon after discharge. Their efforts are directed at providing the best
care appropriate to improve patient outcomes. But there are some
clinical conditions that are inherently unstable, or that can have
unavoidable complications, that can result in the need for readmission.
Also, in spite of outreach efforts, socioeconomic variables can result
in destabilization of the patient's condition. Some readmissions are
This report is important because it shows that the improvement in
lowering readmission rates that occurred after the introduction of
penalties is not so much due to improved inpatient and post-discharge
management, but rather is due to gaming rules that are characteristic of
pay-for-performance (P4P) schemes.
Specifically, there has been a dramatic increase in placing patients on
observation status instead of formally admitting them to the hospital.
The care may be identical - provided in the inpatient service
departments - but by not certifying the patient as being a formal
readmission within 30 days of the last admission, the penalty is
avoided. Medicare comes out ahead since outpatient services are priced
lower than inpatient services, even if they are identical services -
thus the trumpeting by CMS of another success in their reform efforts.
But the patient loses since the cost sharing requirements for outpatient
services are much higher than they are for inpatient. But then who ever
said that health care reform was to benefit patients?
A variation of this gaming is to manage the followup hospitalization
completely within the emergency department, perhaps even holding the
patient overnight. The result is essentially the same as holding them on
This P4P-type gamesmanship is really a form of cheating. But it works.
Instead of shifting to a much more efficient financing infrastructure -
a single payer system - we can continue to follow the Banksy dictum -
"Become good at cheating and you never need to become good at anything
Maybe we should start to think about becoming good at financing health
at 12:06 PM