By Joseph Burns
Health policy experts caution that when health care purchasers tinker with payment incentives, the results can often have unintended consequences. In recent years, federal policy makers have raised concerns about the unintended results from Medicare’s Hospital Readmissions Reduction Program (HRRP).
In December, researchers published the results of a study of HRRP’s effects on mortality in JAMA that showed a rising number of patient deaths. They also cautioned that more analysis is needed.
Established under the Affordable Care Act in 2010, the HRRP required the federal Centers for Medicare and Medicaid Services to impose financial penalties on hospitals with higher-than-expected 30-day readmission rates for patients with acute myocardial infarction (heart attack), heart failure and pneumonia. Since then, CMS added penalties for high readmission rates for patients with chronic obstructive pulmonary disease, hip and knee replacement surgery, pneumonia and coronary artery bypass graft surgery.
We’ve reported on the HRRP many times. These two articles by Jordan Rau of Kaiser Health News are particularly useful for anyone covering the program: Issues to consider when covering hospital readmission penalties and Reporters can use hospital readmission data to explore key issues
The two articles Rau reported for AHCJ will be useful early next year when CMS publishes its data on hospital readmissions for this year. In addition, journalists will want to keep in mind the concern among health policy experts about the unintended consequences of what happens when purchasers institute financial penalties.
Writing for Modern Healthcare in November 2017, Maria Castellucci reported on this issue, Unintended consequences: CMS’ readmissions program might be harming patients. For that article, she cited a study by researchers Ankur Gupta, MD, and colleagues that JAMA Cardiology published online that month, Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure. The article was published in the print version in January.
Just over a year later, researchers Rishi K. Wadhera, MD, and colleagues published a study in JAMA on Dec. 25, 2018, that dug deeper into the issue. In the study, Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia, researchers reported that after CMS announced the HRRP, readmission rates declined nationwide among those Medicare beneficiaries who had been hospitalized with the three conditions.
The researchers wanted to determine if the financial penalties under the HRRP may have “inadvertently pushed some physicians to avoid indicated readmissions, potentially diverted hospital resources and efforts away from other quality improvement initiatives, or worsened quality of care at resource-poor hospitals that are often penalized by the program.”
At the same time, the researchers recognized that the same measures hospitals used to reduce readmissions, such as improved coordination and transitions of care, resulted in reductions in mortality.
Understanding whether the HRRP has been associated with changes in mortality is significant given that CMS has imposed almost $2 billion in financial penalties since it issued the first penalties in 2012 and that CMS is expanding the program to include readmissions of patients with other conditions, the researchers reported.
In the study, the researchers sought to answer three questions:
- Was the HRRP associated with a change in mortality within 30 days of discharge following hospitalization for patients with the three conditions?
- Was the program associated with a change in the number of patients who experienced death and no readmission, readmission and no death, readmission and death, or no death and no readmission during the 30 days after discharge?
- Was the HRRP associated with a change in mortality within 45 days of hospital admission for the targeted conditions?
”Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day post-discharge mortality after hospitalization for heart failure and pneumonia, but not for acute myocardial infarction,” the researchers reported. “Given the study design and the lack of significant association of the HRRP with mortality within 45 days of admission, further research is needed to understand whether the increase in 30-day post-discharge mortality is a result of the policy.”
One of the reporters who covered this story was Paula Span, who writes the New Old Age column for The New York Times. In her article, “Hospitals Stopped Readmitting So Many Medicare Patients. Did That Cost Lives?” she explained that while researchers documented dramatic drops in readmissions after the program began in 2012, they are asking more probing questions today.
“Are readmissions for those conditions really dropping as substantially as it first appeared?” she asked. “Or has the program’s impact been overstated? Are Medicare patients getting better care, or are they being kept out of hospitals to avoid readmission penalties? Are people getting hurt in the process?”
Answering these questions, Span she wrote, “There’s no consensus on the answers, as research has produced conflicting results.”
Among the reasons for increased skepticism were the Wadhera and colleagues article and an article by Andrew M. Ibrahim, MD, and colleagues that JAMA published in February 2018, “Association of Coded Severity With Readmission Reduction After the Hospital Readmissions Reduction Program.”
Ibrahim and his co-authors wrote that a hospital’s readmission rate can be adjusted based on how a hospitals codes each patient’s severity of illness. “Although these adjustments reflect an effort from the Centers for Medicare and Medicaid Services to avoid unfairly penalizing hospitals caring for patients with higher severity of illness, hospitals can improve their calculated rates of readmission by increasing their coded level of severity,” they explained. “It is unknown whether changes in coded severity of illness explain the previously described reductions in readmissions after implementation of the HRRP.”
Later, they added, “Regardless of whether changes in coded severity of illness appropriately reflect clinical risk, our study demonstrates that increases in coding were responsible for a large share of the observed reduction in risk-adjusted rates of readmission.”
Given all of these issues and unanswered questions, more analysis is needed, as Wadhera and colleagues suggested.
Additional resources for covering Medicare’s Hospital Readmission Reduction Program:
- Look Up Your Hospital: Is It Being Penalized By Medicare? (Rau for Kaiser Health News, March 1, 2019)
- Nationwide Readmissions Database. The NRD is part of the Healthcare Cost and Utilization Project (HCUP) from the federal Agency for Healthcare Research and Quality. Designed to support analyses of national readmission rates for all payers and uninsured individuals, the NRD addresses a gap in health care data: the lack of nationally representative information on hospital readmissions for all ages, AHRQ says.
- Medicare Eases Readmission Penalties Against Safety-Net Hospitals (Rau for Kaiser Health News, Sept. 26, 2018)
- Hospital Readmission Rates in Medicare Advantage and Traditional Medicare: A Retrospective Population-Based Analysis. This research was published June 25, 2019, in the Annals of Internal Medicine.
