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Friday, December 12, 2014

Fewer hospital readmissions,the seen and the unseen and Goodhart's Law

One of the multiple provisions of the Affordable Care Act (ACA) is something called the Medicare Hospital Readmission Program.This provision links provider payments to 30 day readmission rates for three conditions-heart attack,heart failure,and pneumonia.More medical conditions are scheduled to be added to the list including chronic obstructive lung disease (COPD).

Writing in the December 4,2014 issue of the  NEJM Dr. Christine Cassel claims success for this program quoting that national readmission rates decreased from 19% to 17.5%.

 The French economist,Frederic Bastiat writing in 1850 advised his readers that a good economists not only looks as the visible effect,the seen, but needs to consider the unseen or what comes next.

What is seen here is the results of the reporting, what is unseen is the reason(s) for the decrease.

Did more patients end up in nursing homes, did more patients die at home,were more patients treated in ERs and not readmitted,what restraints , if any, were placed on ER doctors to not readmit folks recently discharged,.If someone was admitted to a different hospital did that count in the statistics?.What actions did hospitals take in a effort to minimize the likelihood of patients being readmitted?

The patients who were not readmitted are not seen. What  happened to them? Does this reported decrease in readmission rate reflect better care or just less care in the hospitals? Did more people die at home?Were more patients prematurely placed in a hospice care setting?

Thomas Sowell tells his readers that in the real world of limited resources and virtually unlimited desires that  most of times we are involved in trade offs and not solutions.What are the trade offs in this reported decrease in admission?

Has the hospital readmission program managed to be an exception to  Goodhart's'aw?

Charles Goodhart,a professor at the London School of Economics,wrote in a 1975 paper that when a measure becomes a target it ceases to be a good measure.

Although not discussed explicitly  as a example of Goodhart's law, Dr. Cassel also reviewed the ill advised six hour rule for the administration of antibiotics in patients with community acquired pneumonia.It turned out that ER personnel were too profligate in the administration of antibiotics so as to not get cited for poor care. They were like school teachers who "teach to the test".

Dr. Cassel said that the data validated the readmission policy approach. Can you claim that without knowing the mechanism(s) for the fewer readmissions? Do we know if the decrease helped or harmed patients? There was less expenditures from CMS in the hospitalization category but what costs were incurred and by whom?

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