One of the key provisions of the Affordable Care Act concerns hospital readmission rates.  Essentially, readmissions to the hospital are deemed as bad, a thing to be reduced by carrots and sticks.

Logically, that makes perfect sense.  To laymen, the idea that we can screw things up in the hospital and then get paid again to fix our mistakes is silly.  The home builder and the mechanic don't get that deal.  Doctors and hospitals should not either.  So, new rules.  New carrots and a lot a new sticks.

As policymakers would have hoped, a lot of hospital systems and their physicians are working to reduce readmission rates because it is the right thing to do and real money is at stake.  There has been a lot of light shone on the issue of medical errors over the past decade and we're finally getting a real mobilized effort to fix those problems.

But I was in a recent discussion with some people who have some knowledge on these issues and they raised an interesting point.  Who goes to the hospital most of the time in this increasingly outpatient world?  People who are really sick, as in, multiple chronic conditions sick.  The hospital work may have perfectly addressed the cause of admission with the highest possible quality, but that does not mean the multiple chronic conditions were cured.  They actually followed the patient home. 

If there is a readmission, is it the hospital's fault, or just the logical consequence of the broader patient condition that makes some rate of readmission inevitable?

I am not begging a statistical argument here, nor do I think this is a false polarity, either/or, issue.  But it does raise the point about policy, incentives, and penalties as they relate to really complex problems.

The incentives and penalties will have an effect on behavior, just maybe not the effect that was intended.  And though we may feel better about holding someone accountable, we may not actually be addressing the real problem.