Medicare patients have increasingly checked themselves out of the hospital against the advice of medical staff since 2006, with a temporary spike in self-discharges coinciding with the COVID-19 public health emergency, according to a new claims review conducted by the Department of Health and Human Services Office of Inspector General (HHS OIG).
The increasing rate of acute care hospital discharges against medical advice (AMA) was prevalent across most demographics including enrollee type, hospital size, population density and medical condition, the office wrote in its review published Thursday.
That said, discharges AMA increases were higher among hospitals with lower quality-of-care ratings (as measured by overall hospital quality star ratings) and among dually enrolled patients and those with mental health diagnoses.
The HHS OIG said the rate increases are noteworthy, as Medicare patients who left AMA were more than twice as likely to be readmitted to the hospital or die within 30 days of discharge compared to those discharged to their homes.
“Enrollees with decision-making capacity are empowered to discharge themselves and leave AMA; however, the data show that they are more likely to have poor health outcomes, which raises Medicare costs in the future,” the federal watchdog wrote in its report (PDF).
The review combined previously compiled data from 2006 through 2018 with a new audit of claims paid under the Inpatient Prospective Payment Rule for stays between 2019 through 2023.
Hospitals participating in Medicare are expected to document in the medical record when patients refuse to participate in required discharge planning, the HHS OIG noted, though there is no specific guidance on when to denote a patient is leaving AMA “other than citing the use of clinical guidance.”
The rate of enrollees leaving the hospital AMA has risen by almost 50% since 2006, according to the report, from a rate of 0.68% of discharges up to 0.99% of discharges in 2019. The rates continued rising to a high of 1.17% during the public health emergency and returned down to 1% in 2023, “a rate still slightly higher than the pre-[public health emergency] level,” the HHS OIG wrote.
Thirty-day readmission rates among different patient groups, though higher among those who left AMA, were relatively stable across the study period. On the other hand, there was a spike in 30-day all-cause mortality rates among each group that coincided with the pandemic and has somewhat declined in 2023.
The HHS OIG did not include any specific recommendations to the Centers for Medicare & Medicaid Services or other stakeholders in its report but said its data could be useful “when conducting further research and developing guidance and best practices that can be used to address this growth and improve enrollee outcomes. Finding ways to reduce the rate of enrollees who leave AMA or the poor outcomes these enrollees suffer when they do leave AMA will likely improve the health of the Medicare enrollees and save Medicare costs.”
The findings related to Medicare patients’ outcomes when leaving the hospital AMA are in line with a prior analysis of nearly 20 million all-payer hospital admissions published in 2020.
That study found that individuals discharged AMA have much higher odds of 30-day readmission at significant cost to the healthcare system and lower in-hospital mortality rates compared to others. Together, the difference accounted for more than 400,000 inpatient hospitalization days at a total cost of more than $800 million per year.
That study’s authors floated “tailored interventions that address the particular challenges that patients leaving AMA face, such as communication barriers, mental health/substance use comorbidities and lack of established primary care” as potential solutions alongside risk stratification to identify those at highest risk of AMA departure.