It looks like good news for folks on Medicare who are getting new knees or hips: the hospital readmission rates after these delicate surgeries have dropped significantly, according to a report by AARP’s Public Policy institute.
That’s a big deal, since most frequent hospital treatment under Medicare in 2013 was joint surgery and replacement. Nearly 450,000 people got new knees or hips, and Medicare spent $6.6 billion for their surgeries.
A Promising Trend
The readmission rate within 30 days after hip replacement in 2009 was 42 per 1,000 patients undergoing the procedure. By 2013, it had fallen to 34 per 1,000 patients. For knee surgeries, the 2009 readmission rate was 45 per 1,000 patients, and it fell to 34 per 1,000.
“This is certainly good news for patients and hospitals as well,” said Akin Demehin, senior associate director for policy at the American Hospital Association.
What accounts for the drops? Hospitals have used a variety of techniques, including counseling with patients and caregivers about activity and treatment after discharge; follow-up inquiries with patients about their medications and physical therapy, Demehin noted.
Perhaps the rates of reduction in Medicare aren’t really as good as they seem because hospitals are putting more people on 'observation status.'
Debra Whitman, AARP’s chief public policy officer, agreed. “Fewer hospital readmissions after major surgery like knee and hip replacements are good for both patients and the health care system,” she said.
A Deeper Look at the Data
But wait a minute. The numbers aren’t as good for people too young to be on Medicare — those between ages 50 and 64 — who have undergone the surgery. “For the younger folks under 65, there was very little change,” said Leigh Pervis, director of health services research at the AARP Public Policy Institute and a co-author of the report.
For hip surgery, readmission rates dropped 38 percent for Medicare patients but just 3 percent for patients between 50 and 64. For knee surgery, the decline among the older group was 36 percent, compared with just 12 percent among the younger group.
What’s going on? “Our results are clearly promising from a Medicare beneficiary perspective,” said the study, titled Impact of the Medicare Hospital Readmission Reduction Program on Hospital Readmissions Following Joint Replacement Surgery.
Maybe hospitals aren’t working hard enough to keep the younger surgical patients from coming back, however, the report suggested: “The relative stability in readmission rates among the 50- to 64-year-old population raises concerns that hospitals could be focusing their readmission reduction efforts on Medicare beneficiaries rather than the broader population.”
Let’s add another piece to this confusing puzzle. Perhaps the rates of reduction in Medicare aren’t really as good as they seem because hospitals are putting more and more people on “observation status,” which means you go to the hospital, get put in a bed and treated, but aren’t counted as an official admission.
That’s been happening because hospitals have been pushing hard to reduce readmissions among the Medicare population since 2012, when the federal government began levying financial penalties for readmissions. Hospitals have paid $420 million in fines between 2011 and 2014 for readmissions, according to a Kaiser Health News report.
If the hospital classifies a patient who returns within 30 days of surgery as an observation case rather than an official admission, it won’t be dinged for a readmission, which carries a financial penalty.
“In the new world of readmission penalties, some clinicians may be placing returning Medicare patients under observation rather than admitting them,” said a blog post by Health Affairs called, “Is Observation Status Substituting For Hospital Readmission?”
“Our independent analysis of Medicare data published by CMS [Centers for Medicare and Medicaid Services] revealed that the top 10 percent of hospitals with the largest drop (16 percent on average) in readmission rates between 2011 and 2012 also increased their use of observation status for Medicare patients returning within 30 days by an average 25 percent over the same time period,” said the post, written by Claire Noel-Miller and Keith Lind, senior strategic policy adviser at AARP’s Public Policy Institute.
Better and Safer Care
So let’s recap what we know:
Readmission rates are falling for people on Medicare who go to a hospital to get new knees or hips. That’s good news.
But how much this figure is influenced by people going on observation status we don’t know for sure.
And, even when the readmission rates go down, there are still significant areas needed to make hospital care better and safer, says the AARP report. Lots of problems come from the devices providing the new knees and hips. They could become infected; they could be improperly installed. The AARP study said: “It is notable that device complications were responsible for a large share of hospital readmissions following a hip or knee replacement. In fact, the share of hospital readmissions linked to device complications actually increased between 2009 and 2013 among the 65- to 84-year-old age group.”
Medical “experts have consistently expressed concerns that the U.S. Food and Drug Administration does not adequately regulate the safety and effectiveness of medical devices like artificial joints. The results of our analysis should serve as a warning to supporters of recent efforts to further reduce such oversight,” the study said.
Wildly Different Costs and Experiences
The rate of hospital readmissions may have gone down, but consumers still face wildly varying costs and experiences, depending on which hospital they use as the place to get the new knee or hip. Medicare spending for this ranges from $16,500 to $33,000. And “ the rate of complications like infections or implant failures after surgery can be more than three times higher at some facilities than others, increasing the chances that the patient may be readmitted to the hospital,” according to CMS.
To fight these variations, CMS announced on November 15 a new rule aimed at controlling cost and quality by imposing a single payment for all care during a 90-day period starting when a person enters the hospital to get the new knee or hip. It would cover the surgery and any post-hospital care or readmission if something goes wrong. This shifts financial risk to the hospitals, which are unhappy with this approach. The new payment model starts next April at 800 hospitals in 67 metropolitan areas. If it saves money and cuts down complications, it will eventually be expanded to all Medicare hip and knee surgeries.