Hospital Discharge and the Transition Home for Poor Patients: “I Knew I Couldn’t Do What They Were Asking Me”

Abstract

One of the most contentious aspects of the Centers for Medicare and Medicaid Services’ (CMS) Hospital Readmission Reduction Program, which penalizes hospitals for higher than expected readmission rates, is that patient socioeconomic status (SES) is not accounted for (i.e., not risk adjusted for) when calculating hospitals’ readmission rates. Hospitals argue that this disadvantages institutions that care for high proportions of low SES patients because poorer patients have inherently higher risk of readmission. They further contend that hospital interventions to prevent readmissions will not be successful.1 Policy makers on the other hand point out that if hospitals caring for low SES populations have higher readmission rates that may reflect inadequate quality of care—exactly what the measures are intended to illuminate—and should spur improvement efforts to ensure high-quality transitions from the acute care setting.2 At its essence, this is a debate about the extent of hospitals’ responsibility to patients of low socioeconomic status and the degree to which hospitals can influence, within the small window of the inpatient admission, a patient’s trajectory over 30 days following discharge. And all the while, millions of dollars are now at stake through CMS’s Hospital Readmission Reduction Program.