Policies Like the Hospital Readmissions Reduction Program are Killing Patients & Harming Care. It’s Time to End Them.


Federal programs designed to cut costs and improve health by penalizing doctors and hospitals are failing at an alarming rate. Some of them actually harm patients, and many don’t cut costs. One in particular, the Hospital Readmissions Reduction Program (HRRP), may have caused thousands of deaths instead of preventing them, and probably hasn’t saved money during its seven years in operation.

The Centers for Medicare and Medicaid Services began reviewing the safety of this program on Jan. 19. It shouldn’t take CMS nearly four months to err on the side of caution and pull the plug on it.

The HRRP was imposed upon Medicare by the Affordable Care Act. Its goal makes sense: reduce the number of patients readmitted to hospitals soon after being discharged. But its approach — penalizing hospitals millions of dollars if their rate of readmissions within 30 days exceeds an arbitrary threshold — makes no sense at all.

The HRRP and other federal “pay for performance programs” were under fire before they began. Evidence suggested that some hospitals would try to avoid penalties by not readmitting patients within the 30-day window, or if they showed up in the emergency department during that time would treat them there and send them home or place them in so-called observation units rather than admitting them to the hospital. There were also indications that these kinds of programs would disproportionately harm socially disadvantaged individuals.

Influential health policy experts either ignored this evidence or downplayed it.

The behavior of the Medicare Payment Advisory Commission (MedPAC), an independent federal body that advises Congress on Medicare, illustrates the problem. In its June 2008 report published two years before the HRRP readmission penalties were enacted, 16 commissioners voted unanimously that “Congress should direct the Secretary to reduce payments to hospitals with relatively high readmission rates for select conditions.” The commission’s untested theory was that punishing hospitals for excess readmissions would nudge them to offer better discharge instructions and more services, such as nurses calling patients at home after discharge, which would somehow improve health so much that readmissions would drop.

The commissioners voted for this approach even though it had never been pilot tested and they could cite no evidence for it. They were, however, aware of its risks. In a section of the same 2008 MedPAC report, entitled “Undesirable responses,” the commissioners presaged the harm that the readmissions program could cause by listing possible negative side effects of the readmissions policy, including denial of care for “certain patients,” such as those who are frail or senile or who have trouble sticking with their management plans.

Long before MedPAC recommended the HRRP to Congress, research had already shown that readmission rates are heavily influenced by factors beyond hospitals’ control. The long list of factors that influence readmissions include, among other things, low incomelimited educationracepoor diet, and not taking medications as prescribed. Medicare does not collect data on these key factors and, even if it did, it is impossible to predict how they affect hospital readmission rates. Hospitals that care for larger numbers of poor and very sick patients have paid millions more in HRRP penalties than hospitals that treat a smaller number of such patients, offering proof of this point.

A year before the HRRP began, hundreds of economists and health policy experts signed a letter to Congress defending Affordable Care Act programs that penalized doctors and hospitals for undesirable outcomes — such as readmissions — that are influenced by factors outside of physician and hospital control. These experts asserted without evidence that the ACA “contains essentially every cost-containment provision analysts have considered effective in reducing the rate of medical spending.”

The evidence hasn’t supported their optimism.

Large and rigorous studies have shown that death rates among hospitalized individuals rose after the HRRP beganlikely because some critically ill patients were not re-hospitalized and given the inpatient care they needed. Equally worrisome, the discriminatory penalties were disproportionately levied on so-called safety-net hospitals that care for a high number of poor, uninsured, and very sick people. These hospitals are often underfunded to begin with, and the HRRP imposed a kind of reverse Robin Hood effect. This stealing from the poor is a problem with other pay-for-performance nostrums.

The most troubling data come from two recent studies of the HRRP that were published in the Journal of the American Medical Association. The largest of these examined its effects on death rates among patients with heart failure, heart attack, and pneumonia within the arbitrary 30-day post-discharge period. The authors reached three disturbing conclusions:

  • After readmission penalties were imposed, there was a significant increase in death rates among people with heart failure.
  • This increase occurred largely in patients who were never readmitted to the hospital but who died within the first 30 days after discharge.
  • There was almost no change in death rates among patients who had been readmitted to the hospital.

The study observed almost the same increase in pneumonia deaths. A smaller separate study also observed an increase in heart failure deaths.

And just two months ago, another time trend study published in JAMA also observed visible increases in heart failure deaths after the start of HRRP.

The likely reason for the increased death rates was that readmission penalties led to some people being denied lifesaving hospital admissions.

To make matters worse, the HRRP doesn’t even seem to save money. Studies show that it may have caused some hospitals to increase their use of emergency rooms and workarounds called observation stays in which patients are placed under observation in the hospital but are not admitted as inpatients, and so don’t count as readmissions.

The HRRP isn’t the only evidence-free federal penalty program that has failed to cut costs and that may be harming patients. Studies of other pay-for-performance programs demonstrated that, instead of improving care, they induced some doctors to “fire” their sickest and poorest patients to raise their quality scores and payments. A large Medicare physician pay-for-performance program known as the Merit-Based Incentive Payment System (MIPS) has been roundly criticized by several studies, including one published on Monday. Their work persuaded the Medicare Payment Advisory Commission to recommend to Congress that MIPS be repealed. MedPAC voted to repeal MIPS in January 2018. Although that decision attracted substantial attention in the health policy world, we haven’t heard a peep about it out of Congress, suggesting that MIPS could stay in existence for years.

The “wellness penalty” is another example of a risky program authorized by the Affordable Care Act. It lets employers increase health insurance premiums for people with high cholesterol or high blood pressure or weighing too much (any of which can be caused in part by genes) who don’t participate in wellness programs or improve their cholesterol, blood pressure, or weight. Some people have refused to participate in this kind of “preventive” testing and quit their jobs because they are worried that their records may not be private, raising fears of reduced employment opportunities in the future. A large controlled trial recently showed that such legislated wellness programs yield no health benefits, despite the efforts of a bloated $4 trillion “wellness” industry that has received business and government subsidies for decades.

Lazy thinking by legislators and advisers must stop. Policymakers must adopt a code of ethics analogous to the oath doctors swear to first do no harm. Just as we require controlled trials showing that new drugs are safe and effective before they can go on the market, we need to insist on the same standards for health policies. Objective methods already exist to measure the effects of national health policies. But doing this will require less hype, more honest interpretation of research, better awareness of the influence of special interests (including a vast consulting industry), and more circumspection from academic leaders when advising Congress.

If we agree that health policies should be shown to be safe and effective before implementation, then it follows that risky programs like the HRRP should be terminated.

Stephen Soumerai, Sc.D., is professor of population medicine, founding and former director of the Division of Health Policy and Insurance Research, and teaches research methods at Harvard Medical School. Kip Sullivan, J.D., is a member of the policy advisory board for Health Care for All Minnesota and the Minnesota chapter of Physicians for a National Health Program.

This post first appeared in Stat News and is published in The Deductible at the request of the authors.

30 thoughts on “Policies Like the Hospital Readmissions Reduction Program are Killing Patients & Harming Care. It’s Time to End Them.

  1. Kip and Stephen

    Excellent essay. Over the past few years I’ve heard many people calling for clinical trial-like testing before new policies are implemented on the national level. Is this an idea you support? Can you give an example of what a clinical trial for an policy intervention would look like?

    What’s reasonable to ask? How much benefit of the doubt should we give?

    / j

    1. Re: The wellness penalty. This shouldn’t mean all parties shouldn’t make efforts to create a healthier populace; it’s just that punitive actions aren’t necessarily the answer. This coincides with the ineffectiveness of increasing prison time in hopes crime will decrease.

      via TweetBot

    2. Any med policy based on economic principles will fail. Medicine is an individual patient, cottage industry of communicating benefit versus harm trade-offs and encouraging people to make own choice. CMS out of date, out of useful ideas because $ matter too much to them

  2. Kip and Stephen-

    What a wonderful essay!

    IF, the government is incentivizing doctors to NOT provide care
    THEN more patients will die. This seems like a no-brainer.

    The question now is: should we save money with stupid untested policy or save lives by letting doctors do their job?

    The answer has always seemed obvious…


  3. Thanks Niran: This is in response to Niran’s question regarding the perverse effects of incentivizing docs, and the lack of decent pilot tests mentioned by John.

    Unlike many of the (flawed) CMS demonstrations which invited the best performing institutions which volunteered for policies like ACOs (and compared them to non-comparable uninterested ones), prior data existed decades before this HRRP policy that it might be dangerous. We knew of course that hospitals differ in the proportion of vulnerable patients. These often include social characteristics described in the essay that we have known about since at least the 1990s that indicate a vulnerability to readmission. Risk adjustment is and always has been helpless in evening out the playing field in terms of these patient characteristics.

    These many studies already proved that the policy was likely dangerous before it was put into the ACA. (Now Trump wants to make it even worse by reducing incentives and maximizing penalties.) Penalizing hospitals $millions for taking care of rural, poor, medication non-adherent, frail, non-English speaking, and even abused patients makes hospitals pay more for doing good — caring for patients who are sicker and cost more. This is discrimination. And it causes some unintended consequences like trying to “observe” very sick patients instead of admitting them. We believe this is why mortality increased for diseases like heart failure.

    We agree that it is better to give resources for things that improve outcomes. Charging millions for outcomes that are beyond hospital control violates common sense.

    Like Niran, we believe that penalties are not the way. We should appeal to the best, not the worst in human behavior. They almost never work in cost containment policies. Yet they are the “go to tactic” in essentially all the cost policies in the ACA. Some economists (sadly some in Boston) promoted these policies even when they knew of some of their risks. As usual, they thought they might fix them as they evolved. That didn’t happen for the MIPS pay for performance policy, nor “wellness” penalties also built into the ACA, nor this one. It is hard to forgive because we re taking about patient harm and the prior evidence suggested no benefits and excess costs as well.

    Kip and I are not only wedded to randomized trials as pilot tests. We believe there is a hierarchy of good and bad research designs that result (on average) in good and bad evidence. We should choose the best ones first that are feasible.

    Below is a table in one of my and Ross Koppel’s papers; this one actually says that some quasi-experimental designs (not randomized) can yield good evidence. Also, look at the graphs of interrupted time series analyses that provide causal inference about the effects of certain policies. Several of the studies of death rates in our essay also used this method. We do not believe trials are the ONLY way. But we should never believe that more than about 80% of health policy experiments are reliable. Health policy science is mostly untrustworthy (the bottom of the table or comparing the haves to have-nots in the CMS demonstrations) In the words of our friends at the Leonard Davis Institutethis represents “BS in Health Care.” Regardless, we support pilot testing for safety and efficacy, where feasible, and we are certain that CMS could have done a better job than NOTHING or junk science to see if their policies were a risk, benefit or boondoggle BEFORE they foisted it on the entire population.


    Best, Steve

    1. I have absolutely no expertise in this area but I can ask: What is the comparison group? There are many systems around the rich world with hospitals, doctors, and payers. We poke around with blunt instruments like readmission rates when our overall performance in terms of disparities and costs is abysmal. To a physician / engineer, our random walk through policy space seems like a waste of time, at best.

      We doctors are complicit. We call for “evidence based practices” while ignoring the most obvious evidence there is.


      1. Sometimes “evidence-based practice” is more like “let’s try shoving a square peg into a round hole because it should work…” There was no evidence ever that penalizing readmission to the hospital would be good for people. Someone please correct me if there is some small study where this was true (doubtful.)

        This is one of those common sense things where if a patient needs readmission, they need readmission. It isn’t a failure on anyone’s part. It is just part of practicing medicine, the body fails us.

        What policy makers “believed” is it would save money. It didn’t, even after increasing bad outcomes for patients.

        Sometimes science doesn’t make sense. The best example I can think of is this: Swim lessons do not reduce the risk of death by drowning. This is a scientifically true statement, no matter how hard to believe. It is even reproducible.

        Everyone wants to believe that if children learn to swim, then they are less likely to drown. And people want it to make a difference. But it just doesn’t. There are some very small studies where maybe this is true; it doesn’t change the premise that swim lessons don’t prevent death from drowning.

        The reason is probably because death from drowning is not caused by inability to swim in general; it is caused by an inability to swim or stay afloat AT THAT particular moment. That is not only a skill thing per se, rather a serendipity thing plus a little skill.

        The same is true for rehospitalization. It is a crapshoot. Sorry, but true. It is based on so much more than the condition of the patient. It is about their home, support from family, job, socioeconomic stability, food intake, not smoking etc. etc. How is that related to the hospital in any way? How is that related to the physician who takes care of the patient?

        It is not.

        So why are we paying those people for outcomes they cannot control?

      2. John, you began this thread by noting that many people are calling for trials of proposed programs before they’re implemented (Steve and I are obviously among them) and you asked what such a trial might look like.

        I want to note at the outset that this problem of unleashing untested nostrums on the entire populace is two-fold: There’s the problem of not testing at all and unleashing the nostrum on the populace the HRRP is an example); and there’s the problem of conducting a test which demonstrates the nostrum failed, but unleashing the nostrum on the populace anyway (the Medicare ACO program is an example of this problem).

        I will illustrate the latter problem in this post.

        In a rare manifestation of respect for the “first do no harm” principle, Congress actually asked CMS to conduct a test of the “accountable care organization” in 2000. CMS conducted the Physician Group Practice (PGP) Demonstration between 2005 and 2010. CMS put potential participants through rigorous interviews and selected only those most likely to succeed. Here’s the list (from p. ES2 of the final evaluation https://downloads.cms.gov/files/cmmi/medicare-demonstration/PhysicianGroupPracticeFinalReport.pdf ): 1) Billings Clinic, 2) Dartmouth Hitchcock Clinic, 3) Everett Clinic, 4) Forsyth Medical Group, 5) Geisinger Clinic, 6) Marshfield Clinic, 7) Middlesex Health System, 8) Park Nicollet Health Services, 9) St. John’s Health System, and 10) University of Michigan.

        According to the final evaluation of the PGP demo, “Seven of the 10 participants had currently or previously owned a health maintenance organization (HMO).” (p ES3)

        Unlike a half-dozen “studies” of ACOs published in the last four or five years where the investigators set up simulated control groups after the fact, CMS selected local control groups for each of the ten PGPs prior to commencing the experiment.

        You might think that if a half-baked idea like the ACO might succeed, it would succeed in the PGP. Nope.

        The final evaluation concluded that the PGPs saved net (that is, substracting the bonus payments Medicare paid out to the PGPs that allegedly saved money) a mere three-tenths of one percent of total spending for Medicare. This was bad enough. But the report also said that if the PGPs hadn’t upcoded more aggressively than their controls, there would have been no net savings at all.

        Finally, as if that weren’t all bad enough, the evaluation report made no attempt to determine how much the PGPs spent in their futile attempt to save money for Medicare.

        Did this give ACO buffs pause? No sirree.

        Results were already coming in on this doomed PGP experiment in 2009 when Democrats on the key congressional committees began huddling behind closed doors to write what would become Obamacare. Moreover, the CBO warned the Democrats in a December 2008 report that ACOs would save no more than a few tenths of a percent (again not counting ACO overhead).

        But none of this matter. As was the case with the HRRP, the flimsiness of the ACO proposal (the ACO to this day is impossible to define) and the evidence against it was ignored. The authors of the ACA went right ahead and included a provision in the ACA requiring CMS to unleash an ACO program on the entire fee-for-service Medicare population. CMS complied by setting up three ACO programs, all of which are failing to cut costs and all of which are shifting resources away from providers who treat a disproportionate share of the sick and the poor to ACOs that treat a disproportionate share of the well off and healthy.

        So we need the health services research community and lawmakers to adopt a two-fold pledge: “I pledge to test my half-baked ideas on a small portion of the populace first; I pledge to honor the results if they turn out negative.”


      3. I do appreciate the nuanced debate about how stuff like this should be rolled out, but I don’t see how in its current form this type of activity is legal, let alone ethical, no matter the size of the initiative.

        Where is the informed consent of the subjects? If one possible outcome is death or injury, why shouldn’t human subjects be asked if they agree to participate? Why is no State AG prosecuting? Why is nobody bringing a civil class action suit against the government for mass murder, or at least negligent manslaughter? I am pretty sure that buried in the data, is the identity of actual people who were harmed and thus yhave standing. This is not going to stop until the courts intervene.
        [Trigger Warning: Political note – the self-described righteous #resistance is using friendly courts to hamstring practically everything this administration is trying to do, so why not take this “initiative” to court too? Seems like an opportunity to me….]

        If you want to experiment with cutting costs by cutting corners (disguised as quality improvement), so be it. But then, you should ask people if they agree to participate. If they do, count them in the “quality program” denominator. If they don’t, exclude them from your “performance” calculations. And people who are mentally incapable of giving consent, should be excluded automatically.
        I know this is not as good as secretly putting all patients through the same meat grinder, and I know an opt-in protocol is rife with cheating avenues, but I believe we decided post Nuremberg that research does not take precedent over human rights.

      4. Margalit, thank you! All this outcomes stuff has almost literally buried the patient in the charts. Medicine used to be a practice and an art, and I think it still is. Relationship between patient and doctor has influence over recovery.

      5. Thank you Margalit. Research is often too slow. It took 9 years! between passage of the readmission penalties in the ACA and the several studies showing likely patient deaths. Since then we can only assume that the harms continue.

        The common sense of all of you should have prevailed before exposing patients to harm.

        It is worth clarifying that the data that existed decades before enactment of the HRRP were not complex policy impact studies but simple correlations that convincingly showed that readmitted patients had an above average number of many medical and social vulnerabilities that put them at higher risk of being admitted regardless of what the hospital did. I recall that some OLD studies showed that up to 75% of readmissions were not preventable. So how can penalizing hospitals for largely non-preventable admissions do anything but harm?

        I am aghast that only cheerleaders of economic “incentives” influenced the original policies. How is it that people who are in the field–especially practicing doctors–were left out of these risk-benefit decisions?

      6. Don’t forget that a rise in readmission may be due in part to a earlier stupid CMS policy of capitated in-patient care? Incentive was to get patients out so LOS became a target perhaps fueling readmission. Also, CMS is so smart that medicare part A will make a patient pay more if the patient is admitted after a certain time period, I think, 60 days. So, get back in sooner rather than later. Economists will always make stupid doctors and doctors will be stupid economists.

      7. One of many studies:

        JAMA Intern Med. 2016;176(4):484-493. doi:10.1001/jamainternmed.2015.7863

        73 % of 1000 IM patients’ 30-day readmissions were not preventable at 12 academic medical centers. The study made much of the possibilities for more humane efforts to provide resources to reduce the 27% of preventable admissions. But, obviously, setting an arbitrary threshold for hospitals and penalizing them $5 million for exceeding it is not what they were talking about. That (HRRP) approach is fraught with error and harm. S

      8. A nice article and a reminder—if one were needed—of how immensely complicated health services can be and the risk of unintended consequences.

        The complexity is such that we shouldn’t exclude some positive outcomes of the policy, of which there were some. At Cedars-Sinai, we looked at our patients who were at highest risk of re-admission. Not surprisingly, this turned out to be the population discharged to skilled nursing facilities. Analysis showed that a significant number of these patients were not seen in follow up within the first few days of their stay. A program was initiated to have a nurse practitioner visit the patient within 24 hours of discharge. Those visits ended up helping with medication reconciliation and early recognition of UTIs and other common problems that lead to re-hospitalization. The program ended up reducing re-hospitalization rates by something like 30% and the results were published. Early NP visits—a great innovation for an often neglected population– never would have been considered without the change in reimbursement policies.


      9. Adrian: If you think the HRRP will hit an iceberg and sink, I am all ears!

        I personally feel like an historian documenting the causes of a disaster for future generations. But how can a deadly provision of a law be repealed? Maybe is possible to remove some of the poison? S

      10. Good questions, Margalit. I have a few minutes to comment on your consent question. Hope to comment on your lawsuit question later.

        Patients should be asked for their consent before they are pushed into a program that could harm them. There are, broadly speaking, three reason why that never happens.

        First, health policy researchers and policy-makers long ago adopted a set of informal rules that imposes one set of flimsy standards on themselves and a much more rigorous set of standards for doctors, hospitals, and drug companies. Second, it is often impossible or extremely expensive to determine which patients are or will be swept into them one of the risky “value-based payment” programs that so captivate politicians of both parties and large swaths of academia and the think-tank world. Third, even if we could track down the millions of patients who have been exposed to ACOs or some other risky “value-based payment” scheme, no one can explain to anyone else what it is the most visible schemes do. What would you want to say to a patient on a consent form about ACOs, for example?

        First, the double standard invented by health policy gurus — one for them and another one for health care professionals. I could go on at great length about the attitudes regarding evidence and patient harm that are now widely shared among health policy experts and policy-makers. Suffice it to say here there is a widespread belief within the health policy aristocracy (those who make or influence policy) that doctors must honor the “first do no harm” principle and the principles of evidence-based medicine, but the aristocracy bears no similar burden of proof (they can propose any risky fad without evidence of safety or effectiveness). People who think they have no obligation to pre-test their risky ideas are not likely to wonder if patients need to be warned of the risks.

        The second problem: It is impossible to know in advance or in real time whether patients will be, or are, exposed to the most visible “value-based payment” schemes currently administered by CMS; or it is possible to know but notifying all of those patients and extracting anything resembling informed consent would be very, very expensive.

        Third, the services that will be deployed for or against patients by the largest of the “value-based payment” schemes (ACOs, MIPS, the HRRP, bundled payments) are extremely difficult to describe even to experts, much less to ordinary mortals who have no idea what “accountable care,” “integrated care,” “potentially preventable readmission,” or “transformation” mean. This is a problem because proponents of these schemes never lay out the mechanisms they are supposed to use. They just lay out their aspirations for these things

        Medicare’s ACO programs illustrate the second and third problems. Patients don’t know when they’ve been assigned to an ACO, and the pool of patients assigned to an ACO changes dramatically every year (the ten PGPs in the PGP demo, and the ACOs in Medicare, lose about one-third of their assignees per year). Doctors often (perhaps I should say usually) don’t know which patient has been assigned to an ACO. Finally, it is typically the sickest patients who stand to lose or gain from whatever it is ACOs do, which means in most circumstances there would be no point in trying to explain to healthy patients what an ACO does to or for patients, that is, what it is they are consenting to.

      11. Stephen-

        Practicing doctors are ALWAYS left out of these decisions.

        It’s the Andy Slavitt’s of the world —who have never practiced one day in their life— that make these decisions and then go on to do something else with their lives.

        There is still no one asking practicing physicians about such things despite failure of their methods.

      12. The Titanic I’m talking about (and I think Niran is as well) is the role of the physician as the patient’s agent _without any conflict of interest_.

        Having physicians, or at least one physician, you can trust would moot most of the specifics we’re discussing.

        The hospitals, administrators, bureaucrats, and pundits will keep rearranging the deck chairs because they are being paid to do so. Almost everything they do can be explained as having the physicians work for them instead of for the patient. Because the physicians have to write the orders this is the institutions’ prime directive.

        The solution, here in the US or in other rich economies, goes through the physician as the learned intermediary. We can argue about how physicians are paid. Some physicians can be paid out-of-pocket by the patient. Other physicians can be employed as part of a surgical team or an ER. A few physicians will be paid by the payers to push back on suspicious claims by doing their own patient evaluation.

        Shifting the regulation of healthcare to hospitals and other data brokers screws the patient.

      13. Adrian!!!!!


        Yep. One doctor and one patient together, or as I often say, “me and my patients against the world.”

        In other news look at how corporate interests destroy the lives of children. Also notice how many are on Medicaid.

        The system is two-tiered. And this is just one example. The government cannot fix this.


      14. As a friendly amendment to my friends’ (Kip and Steve S) wonderful posts:

        I think few in healthcare, economics or healthcare are especially savvy about research design. They don’t perceive the massive methodological faults in the studies they like. Steve and I have written several articles and op eds about this.
        Neoclassical economics is the zeitgeist of American discourse and thought. Few realize that neoclassical economics is based on an unrealistic model of the nature of human nature or that econometric models depend on steep mountains of often absurd assumptions.
        The complex math of modern economics is overwhelming to most readers. The magic of the models and the generous display of formulae are so impressive as to discourage looking behind the green curtain. Of course the emperor’s new clothes are wonderful
        As Steve said a few posts ago, he and I have published several articles with methods for examining healthcare policy that do not depend only on RCTs…which can only be used in some cases. Specifically, we present example of ITS methods (interrupted time series) that address many of the concerns noted here.
        Behavioral economics, the darling of the current policy wonks, is largely based on neoclassical economics, and suffers most of the weaknesses noted above (in point no. 1)
        Last….and speaking to Kip’s and Margalit’s most recent posts…. I think the unquestioned belief in the wisdom of neoclassical economically-based assumptions about policy and motivation blinds policy makers to the reality that they are affecting people’s lives–often in unknown or negative ways. They see the proposed policy as “obviously” better than whatever exists currently. In their thinking, there is no need to seek consent or to conduct additional testing.

      15. Kip, to answer your question about consent, let me start with the original item, e.g. denying patients readmission to a hospital. Creating an opt-in consent process should be pretty straight forward, I think. Hospitals would have no incentive to send very sick people away if they can exclude them from measures (I know, I know…. but integrity can be ensured at least as much as it is now with the “observation” games, which by the way have the fortunate effect of also dumping all sorts of charges on the patient so Medicare gets to save even more…).

        A simple form describing the program in one sentence (e.g. This hospital makes more money if you are not readmitted to our services within 30 days after your discharge. We will do everything in our power to keep you out or service you in the ER (extra charges may apply) for the 30 days period. If you agree to participate and help us stay profitable, please sign here:_____________ You are not required to participate and our services will be the same whether you do or don’t….. or something like that)

        For ACOs it is also up to each physician or hospital that participates in an ACO, or any other scheme that rewards for value, should notify every patient that comes through the door about the program, so they can go elsewhere if they wish to.

        Here is my form for that: This facility is receiving money from your insurer if your total costs of care are lowered and is assessed fines if the cost of your care here and elsewhere exceeds the expectations of your insurer. You hereby give this facility consent to adjust and modify clinical advice and therapies if any to maximize our payments, and minimize our penalties, due from you insurer. We cannot accept you as a patient or treat you in any way if you refuse. Once you give us your consent, you probably can’t sue us or your insurer if we screw up royally on your behalf…. (probably should phrased a bit better, but that’s the gist).

        Patients should be notified of all conflicts of interest before they agree to put their health and maybe life in the hands of any particular physician or hospital. This includes referral arrangements, value based crap, productivity bonuses, etc. I would make them post this stuff on the door and and on the waiting room walls, in big bold letters.

        Y’all want transparency, so here is transparency….

      16. Take a look at this


        This is the tip of an iceberg. There’s a back story and lot’s between the lines

        I wish I could tell you that this tale of sound and fury was peculiar to UNC or was the last act of a very bad play. It isn’t. There are variations at a great many AHCs

        Nothing’s rotten in Denmark by comparison.

      17. Wow. That’s ballsy, Margalit. Love it.

        But please realize that about 60% of admissions to hospitals come thru the ED. There is often little choice. HHS pretends people make rational decisions about which hospital to use. That’s 99% nonsense. People go to hospitals that they can reach, or that the ambulance takes them to, that are within their network, that their doctors tell them to go to, and that their daughters can drive to.

        Imagine I get a seeming heart attack. In the EMS ambulance, while struggling to stay alive, I pull out my laptop, my wifi card with independent access, and I diagnose my cardiological problems, I then enter that information along with my medical history and demographics into a model that will tell me the best hospital within the region based on quality of care, survival rates, etc. Perhaps I have other economic data also to include? I then, assuming I’m still alive, direct the ambulance to the optimum choice based on the aforementioned model. Of course the drivers will take me to whatever place they deem the shortest ride. I’ll have no say in the process. My epidemiological models will be for naught.

        The illusion of choice remains an HHS bedrock.


      18. Adrian: You touched upon something that has been near and dear to me, namely, keeping physicians and particularly PCPs, independent of institutional providers. I tried very hard to do that in RI and had some success, because the PCPs intuitively knew their lives would be better independent and actually trusted us (health insurer…gasp) more than hospitals. Of course, the whole move toward integrated ACOs (if it still exists) would push toward PCPs becoming employees of the hospital-centric ACO. We have to shift the center of gravity. Ahhh, I’m rambling.

      19. Ross, coming from the ED is not a problem. Coming from home or a sidewalk in an ambulance is not a problem. You don’t need to give consent to be included in HRRP before your admission. You need to do that before your discharge. It should be entirely voluntary to opt in. If you don’t opt in, the hospital will just exclude you from the measurement.

        The second scenario I described for ACOs and such, should work precisely the same way in case of emergency.

        People should have an option to not be included in those infernal “quality measures”. This is not currently a choice, but it should be. I don’t see why not….

      20. Jim –
        Imagine if you paid independent docs the same as those who are employed and have more leverage with which to “negotiate”?

        If insurers would incentivize physicians this way, there would be one hundred thousand more of me out there. 🤭 (gasp!)

        Ok, maybe that thought is scary, but I am a really good deal—basically Nordstroms service at Walmart prices AND the lowest hospitalization rate in the state, for excluding Peds open hearts (because those pesky cardiovascular surgeons keep referring every child with congenital heart disease on the Olympic peninsula to me for primary care.)

        Jim you are on to something.

      21. I started down this path albeit too slowly in RI. We increased PCP fees for evaluative and maintenance codes by 50% in three years, formed PCMHs helping to fund them, co-located integrated mental health services with PCPs, and for each PCMH, paid for a nurse case manager to be their employee and be embedded in care and reporting. These were relatively smaller practices. We ran a med school loan forgiveness program for PCPs who came to RI to practice. We helped fund EMRs (I know Niran you ain’t a fan of those). We tried to paint a picture where someday, PCPs would be the hub, and through data and plan design, would direct care to the best quality, best outcome, and (third in importance) lower cost care givers. They’d actually have the data finally to do so. [Of course that hasn’t yet come to pass yet either.] The rule would not be stickiness of relationships and volume/traffic, but quality of care and outcomes informed by cost (which of course equals “value”).

        But CEOs come and go, and eventually I left, and while my successors have tried, it’s so hard to change things. But it’s still a vision that I believe can be viable or at least possibly so where the PCPs haven’t been totally co-opted by becoming institutional employees. I wrote about this several years ago on THCB and still believe in it (and in the tooth fairy too).

    2. I don’t have anything to add, just want to say that I agree 100%. We are not honoring the scientific method, and therefore making mistakes that have already been made again and again. I take that back, I will add something. Tons of research has been done about incentive programs in other industries (and why they are so misguided). This is from 1993 in Harvard Business Review, and I try to get every I can to read it: https://hbr.org/1993/09/why-incentive-plans-cannot-work

      Thanks for the excellent work!

  4. I do appreciate the nuanced debate about how stuff like this should be rolled out, but I don’t see how in its current form this type of activity is legal, let alone ethical, no matter the size of the initiative.

    Where is the informed consent of the subjects? If one possible outcome is death or injury, why shouldn’t human subjects be asked if they agree to participate? Why is no State AG prosecuting? Why is nobody bringing a civil class action suit against the government for mass murder, or at least negligent manslaughter? I am pretty sure that buried in the data, is the identity of actual people who were harmed and thus yhave standing. This is not going to stop until the courts intervene.
    [Trigger Warning: Political note – the self-described righteous #resistance is using friendly courts to hamstring practically everything this administration is trying to do, so why not take this “initiative” to court too? Seems like an opportunity to me….]

    If you want to experiment with cutting costs by cutting corners (disguised as quality improvement), so be it. But then, you should ask people if they agree to participate. If they do, count them in the “quality program” denominator. If they don’t, exclude them from your “performance” calculations. And people who are mentally incapable of giving consent, should be excluded automatically.
    I know this is not as good as secretly putting all patients through the same meat grinder, and I know an opt-in protocol is rife with cheating avenues, but I believe we decided post Nuremberg that research does not take precedent over human rights.

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