I am a long-time proponent of measuring provider performance and aligning it with payment as an effective means for improving the quality of care and with it, patient outcomes.

Because of this, I welcomed the value-based purchasing concepts and quality improvement initiatives that are fundamental to the Affordable Care Act (ACA).

But, as in so many things, the devil is in the details and, despite their best efforts, measure designers can’t always foresee all the ramifications.

Case in point: A provision in the ACA prompted the Centers for Medicare and Medicaid Services (CMS) to establish the Hospital Readmissions Reduction Program to focus attention on ways to reduce 30-day readmissions.

CMS has already begun to reduce payments to hospitals with excess 30-day readmissions for myocardial infarction, heart failure and pneumonia and, by 2015, the reductions will extend to readmissions associated with acute exacerbation of chronic obstructive pulmonary disease and elective total hip and knee arthroplasties.

When the measure was applied in real-world settings, controversy ensued as concerns were raised; two excellent articles in the May issue of Health Affairs shed light on the problem.

The first article (Hu, Gonsahn, Nerenz) describing a retrospective cohort study using data from an 802-bed teaching hospital in Detroit, Mich., reported significant associations between socioeconomic variables and 30-day readmissions for patients discharged from the hospital.

Specifically, after controlling for patient demographics and clinical conditions, the researchers found that patients living in neighborhoods with high poverty (i.e., a high percentage of families with incomes below the federal poverty level), low education (i.e., a high percentage of the population over the age of 25 without a high school diploma), and low household incomes were at greater risk of being readmitted.

A similar study (Nagasako, Reidhead, Waterman, Dunagan) conducted at an urban hospital in Dallas found that residing in a census tract in the lowest socioeconomic quintile was related an increased risk of 30-day readmission.

Moreover, a model using three socioeconomic factors showed that patients living in high poverty neighborhoods were 24% more likely than other patients to be readmitted within 30 days after adjusting for demographic characteristics and clinical conditions.

These and previous findings raise serious questions:

• Does the measure disproportionately affect hospitals that provide care to patients of lower socioeconomic status (e.g., urban teaching hospitals, rural community hospitals)?
• Should CMS’ readmission measure and its associated financial penalties be adjusted for the effects of factors beyond a hospital’s influence; e.g., poverty and lack of social support?
• Importantly, for quality measures in general, is it correct to assume that the thing being measured — in this case, 30-day readmissions — results solely from poor quality of care?

In June, the debate moved to the halls of Congress, where a bipartisan trio of senators introduced the Hospital Readmissions Program Accuracy and Accountability Act aimed at accounting for socioeconomic status when calculating risk-adjusted readmission penalties.

The bottom line is that even quality measures benefit from quality improvement.

David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA, and blogs at Nash on Health Policy and Focus on Health Policy.