Is the Affordable Care Act Doing What It s Supposed to?

Affordable Care Act via Shutterstock Affordable Care Act via Shutterstock

According to a recently published article in the New England Journal of Medicine, a study's authors are making a case for the success that implementation of the Affordable Care Act has had on hospital readmission rates, 30 days after hospital discharge.

The authors have found that hospital readmission rates which have been a financial disaster in Medicare expenditures have declined for targeted conditions (heart attacks, heart failure, pneumonia, knee/hip replacements) and nontargeted conditions (everything else) ever since the ACA was implemented. Although epidemiological data had previously revealed a decrease in 30-day readmission rates, data were lacking to evaluate the effect of the program.

The ACA was passed in 2010, and as part of it the Hospital Readmissions Reduction Program was created to incentivize hospitals by cutting compensation to those facilities that had higher than expected readmission rates.

Why is it so important to reduce 30-day readmission rates? Because, according to the authors readmissions carry a $17 billion price tag, which is considered to be avoidable and those readmissions are both a sign of, and a causative factor in, poor patient outcomes. That estimate seems conservative in comparison to the Agency for Healthcare Research and Quality (AHRQ) the nation's lead federal agency for research on health care quality, costs, outcomes, and patient safety, which found that in 2011 there were 3.3 million hospital 30-day readmissions with a total cost of $41 billion.

The analysis included data for 3,387 hospitals from the 2007 to 2015, from the pre-ACA era and during the ACA era, which found that for targeted conditions, readmission rates declined from 21.5 percent to 17.8 percent, and for nontargeted conditions rates declined from 15.3 percent to 13.1 percent. These rates had the greatest rate of decline in the immediate days after the ACA was implemented and have somewhat plateaued.

It had been postulated that in order for hospitals to avoid the financial penalty for high readmission rates, they would instead treat more patients in clinical observation units, or COUs. About one third of hospitals in the United States have a COU, where patients are sent to be monitored without actually being admitted. The authors found that although there were increases in stays in observation units (from 2.6 percent to 4.7 percent for targeted conditions, nontargeted conditions went from 2.5 percent to 4.2 percent), there was not a significant association between the increased COU stays and decreased readmission rates.

According to an article by Sabriya Rice on the website, Modern Healthcare, Dr. Steffie Woolhandler, a professor at the City University of New York s School of Public Health, feels that hospitals are not incentivized to reduce readmission rates, but to cheat the system and that the authors of the study very likely over-interpret their statistical findings and offer false reassurance about the potential for gaming.

It s difficult to say whether penalizing hospitals really improves patient outcomes. It's just as likely that hospitals forced to provide more intense therapy in emergency rooms or change/exaggerate diagnoses could demoralize those hospitals that are actually doing a good job but not meeting target numbers.

The authors may consider the results of this study a win in the ACA column, but I would be very cautious about popping champagne bottles just yet.