Headline

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations (ACOs) and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

Context

Hospital readmission rates are often used as a quality measure, including for ACOs. ACOs serving members with complex health and social needs — such as multiple chronic conditions, behavioral health conditions, or housing insecurity — may have higher rates of hospital readmissions. This study compared risk factors for individuals with high and low rates of hospital utilization to understand how the quality measure of 30-day readmission rates may negatively impact Medicaid ACOs and safety-net health care providers.

Findings

The group with high utilization had significant social needs and higher rates of chronic conditions as compared to those with low utilization rates. Over 50 percent of all hospitalizations for the high-utilization group led to 30-day readmissions, as compared with under 10 percent for the low-utilization group. This variation can lead to significantly different evaluations of the performance of ACOs based on their member composition — the prevalence of members with complex health and social needs within an ACO is a primary driver of the readmission rate.

Takeaways

The use of “all patients” readmission quality measures should be reconsidered due to their negative impact on Medicaid ACOs and safety-net providers. When using the quality measure of readmissions, a more useful approach may be to exclude hospitalizations of individuals with high utilization, which would limit the effect of patient-level variability on measuring health plan quality.