|WHAT WE’RE READING
Stuff we read this week that made us think.
Are readmissions penalties good or bad?
In recent months CMS’s Hospital Readmissions Reduction Program (HRRP) has been under growing scrutiny, with two high-profile studies questioning whether readmissions penalties have been effective in reducing costs and improving patient outcomes. Here’s a quick summary of the program and recent research and discourse: part of the ACA, HRRP was launched in October 2012 and imposed payment penalties for hospitals who had excessive (i.e. higher than average) rates of readmissions for three common conditions, acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. CMS has largely hailed the program as a success, and a MedPAC report released last summer claimed that the program has reduced readmissions for target conditions roughly 3 percent with no effect on mortality, while saving the government $2B annually.
Two recent high-profile studies question these findings. Writing in JAMA last month, Harvard researchers asserted that mortality for two target conditions rose after HRRP implementation, making the claim that the penalties may have rewarded providers for changing care in ways that proved harmful to patients. Unsurprisingly, the news that readmissions penalties might be bad for patients—fueled by a New York Times op-ed by study authors—sparked a flurry of media coverage. And just this week, research published in Health Affairs questioned whether the program actually lowered readmissions rates at all, claiming that lower rates could largely be due to changes in coding for patient diagnoses and severity that rolled out at the same time as HRRP. Taking these factors into account, authors found no difference in readmissions rates between HRRP hospitals and a control group.
Working through analyses by researchers and economists, it becomes clear that it is impossible today to definitively answer the question of whether readmissions penalties are effective or harmful. Penn researcher Dr. Atul Gupta lays out many of the confounding factors. Studies looking at the correlation between readmissions rates and mortality evaluate different patient outcomes at different timepoints, making comparison difficult. Many studies lack a real “control” group, simply comparing hospitals who lowered their readmissions rates to those who did not, with both likely changing their behavior. And most importantly, several other Medicare policy and market changes occurred at the same time as HRRP rollout and very likely affected the target population characteristics and hospital behavior. Here are just two examples: Medicare’s Recovery Audit Program, or RAC audits, dramatically lowered the number of one-day inpatient admissions, likely raising the average severity of those patients who were admitted. And growing Medicare Advantage enrollment may have also increased severity of the target populations, siphoning off healthier patients. At this point, principled researchers and policy experts can merely cite mounting conflicting data to call for more analysis before expanding the readmissions program further.
An ambitious new plan for the NHS
This week England’s National Health Service (NHS) unveiled its “Long Term Plan”, outlining how the venerable but ailing system intends to allocate the increased funding it was promised as part of the Brexit process. Over the course of the next five years, the NHS is slated to receive an additional £20.5B (about $26B) in funding, which reflects an annual increase of 3.5 percent per year, as part of a Brexit “settlement” announced by British Prime Minister Theresa May last year during the celebration of the NHS’s 70th anniversary. The plan sets ambitious goals for the NHS, aiming to save almost half a million lives over 10 years by deploying a variety of strategies: widely expanded genetic testing, heavy investment in community-based management of chronic disease, a big bet on “social care” and “social prescribing” to address non-clinical drivers of health status, a “digital front door” to the NHS using telemedicine, and a reorganization of structures and incentives to increase the integration and accountability of healthcare providers. In part, the plan reflects a shift from the competition-oriented approach implemented in the last major round of NHS reforms, betting instead on strategies that look more like “accountable care on steroids” than “unleashing market forces”.
Two major questions will confront the NHS immediately as it begins to flesh out details and implement the new plan. The first is access. Given years of chronic underfunding, the NHS faced extraordinary difficulties in maintaining access to services (especially emergency department care) last winter and will likely see even worse wait times and access problems this year. The current strategy of setting rigorous wait time targets for emergency visits and procedures has not worked, and the new plan is mostly silent on the issue. The second (and related) issue is staffing—the NHS is desperately understaffed, and with an aging patient population, the current backlash against immigration that triggered the Brexit vote could not have come at a worse time. Particularly as the system looks to expand community-based care, and bolster services that can reduce the load on its straining hospital system, more healthcare-sector workers will be needed. Yet reducing immigration will constrain their availability, particularly for lower-skilled labor. It’s worth watching how the NHS navigates these challenges, and monitoring the rollout of the Long-Term Plan—both for American conservatives who view the NHS’s problems as a cautionary tale and for progressives who are crafting single-payer reforms. Our healthcare systems face strikingly similar challenges, and we have much to learn from each other’s successes and shortcomings.
Should obese patients bear responsibility for their poor health?
Almost every time we talk about risk-based payment or care management with a group of healthcare leaders, someone asks this question: “How can providers be successful if patients won’t take responsibility for their smoking/lifestyle/eating habits/other bad choices?” This week was no exception, with a health plan leader asking how healthcare costs could be managed if patients don’t take control over their behavior, specifically obesity, which makes “everything more expensive”. That same day, we happened across this excellent article in The Atlantic that provides a first-person perspective on just how hard it is for a morbidly obese patient to “take accountability.”
Tommy Tomlinson is a columnist at the Charlotte Observer who has been obese all of his life, and now weighs 460 pounds. He describes in excruciating detail what it’s like to navigate the world at that weight—and the painful cycle of losing, and then inevitably gaining back the weight, his entire adult life. He addresses straight-on what many thin people think when they meet him: just “eat less and exercise”. He points to how research is beginning to reveal that the bodies of obese individuals may work against even the strongest willpower. One example: obesity experts evaluated long-term weight loss of contestants from the television show “The Biggest Loser”, who lose large amounts weight using a strict diet and exercise regimen. Investigators were shocked to find out that as they lost weight, contestants’ metabolisms slowed to the point of making weight loss nearly unsustainable—and kept slowing even as they gained weight back. This and other studies suggest that formerly obese patients may never be able to “eat like a normal person”, having to perpetually exist in a “near starvation” mode to keep the weight off long-term. Something in our DNA protects us from withering away in times of scarcity and perceives any weight loss as a threat, kicking in survival mechanisms that fight even healthy weight loss.
There is no question that patients need to be engaged partners in care management efforts, and many of us make less-than-ideal lifestyle choices. But often questions about the challenges of individual responsibility seem like easy excuses for not doing the hard work of population health—and with obesity in particular, are laced with bias, judgement and stigma. Tomlinson’s article (like this New York Times piece by the excellent reporter Taffy Brodesser-Akner, who describes her lifelong weight challenges through the lens of Weight Watchers’ rebranding) shows what it’s like to live obese—and should be required reading for medical students. Managing obesity, addiction and many other “lifestyle determinants” of health requires long-term, intensive behavior change support. Or in the words of an overweight cardiologist whom we met at one of our presentations last year, “As an obese man, I know that the advice I give in the office as a doctor, telling patients to ‘eat less and exercise more’ and providing no support beyond that, probably does more harm than good.”