Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program

Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program.

New CMS payment policies present a golden opportunity for pharmacists in health systems looking to justify expanded roles.

The Hospital Readmissions Reduction Program (HRRP) has been associated with a reduction in readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. It is unclear whether the HRRP has been associated with change in patient mortality. To determine whether the HRRP was associated with a change in patient mortality. Retrospective cohort study of hospitalizations for HF, AMI, and pneumonia among Medicare fee-for-service beneficiaries aged at least 65 years across 4 periods from April 1, 2005, to March 31, 2015. Period 1 and period 2 occurred before the HRRP to establish baseline trends (April 2005-September 2007 and October 2007-March 2010). Period 3 and period 4 were after HRRP announcement (April 2010 to September 2012) and HRRP implementation (October 2012 to March 2015). Announcement and implementation of the HRRP. Inverse probability-weighted mortality within 30 days of discharge following hospitalization for HF, AMI, and pneumonia, and stratified by whether there was an associated readmission. An additional end point was mortality within 45 days of initial hospital admission for target conditions. The study cohort included 8.3 million hospitalizations for HF, AMI, and pneumonia, among which 7.9 million (mean age, 79.6 [8.7] years; 53.4% women) were alive at discharge. There were 3.2 million hospitalizations for HF, 1.8 million for AMI, and 3.0 million for pneumonia. There were 270 517 deaths within 30 days of discharge for HF, 128 088 for AMI, and 246 154 for pneumonia. Among patients with HF, 30-day postdischarge mortality increased before the announcement of the HRRP (0.27% increase from period 1 to period 2). Compared with this baseline trend, HRRP announcement (0.49% increase from period 2 to period 3; difference in change, 0.22%, P = .01) and implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%, P = .001) were significantly associated with an increase in postdischarge mortality. Among patients with AMI, HRRP announcement was associated with a decline in postdischarge mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, -0.26%; P = .01) and did not significantly change after HRRP implementation. Among patients with pneumonia, postdischarge mortality was stable before HRRP (0.04% increase from period 1 to period 2), but significantly increased after HRRP announcement (0.26% post-HRRP announcement increase; difference in change, 0.22%, P = .01) and implementation (0.44% post-HPPR implementation increase; difference in change, 0.40%, P < .001). The overall increase in mortality among patients with HF and pneumonia was mainly related to outcomes among patients who were not readmitted but died within 30 days of discharge. For all 3 conditions, HRRP implementation was not significantly associated with an increase in mortality within 45 days of admission, relative to pre-HRRP trends. Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI. 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 postdischarge mortality is a result of the policy.

Hospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014. We sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients. We analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016). We assessed discharged patients ≥ 40years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database. HRRP was announced and implemented during this period, forming a natural experiment. We calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions. COPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions). In Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.

The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences. To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment. Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017. Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014). Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates. The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation. Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.

In this article, we provide a comprehensive, empirical assessment of the hypothesis that the Hospital Readmissions Reduction Program (HRRP) affected hospital readmissions. In doing so, we provide evidence as to the validity of prior empirical approaches used to evaluate the HRRP and we present results from a previously unused approach to study this research question-a regression-kink design. Results of our analysis document that the empirical approaches used in most prior research assessing the efficacy of the HRRP often lack internal validity. Therefore, results from these studies may not be informative about the causal consequences of the HRRP. Results from our regression-kink analysis, which we validate, suggest that the HRRP had little effect on hospital readmissions. This finding contrasts with the results of most prior studies, which report that the HRRP significantly reduced readmissions. Our finding is consistent with conceptual considerations related to the assumptions underlying HRRP penalty: in particular, the difficulty of identifying preventable readmissions, the highly imperfect risk adjustment that affects the penalty determination, and the absence of proven tools to reduce readmissions.

The Medicare Hospital Readmissions Reduction Program (HRRP) is associated with reduced readmission rates, but it is unknown how this decrease occurred. To examine whether the HRRP was associated with changes in the probability of readmission at emergency department (ED) visits after hospital discharge (ED revisits) overall and depending on whether admission is typically indicated for the patient's condition at the ED revisit. This retrospective cohort study used hospital and ED discharge data from California, Florida, and New York from January 1, 2010, to December 31, 2014. A difference-in-differences analysis examined change in readmission probability at ED revisits for recently discharged patients; ED revisits with clinical presentations for which admission is typically indicated vs those for which admission is more variable (ie, discretionary) were examined separately. Inclusion criteria were Medicare patients 65 years and older who revisited an ED within 30 days of inpatient discharge. Data were analyzed from December 18, 2018, to September 11, 2019. Before and after HRRP implementation among patients initially hospitalized for targeted vs nontargeted conditions. Thirty-day unplanned hospital readmissions at the ED revisit. A total of 9 914 068 index hospitalizations were identified in California, Florida, and New York from 2010 to 2014. Of 2 052 096 discharges in 2010, 1 168 126 (56.9%) discharges were women and 566 957 discharges (27.6%) were among patients older than 85 years. Among 1 421 407 patients with an unplanned readmission within 30 days of discharge, 1 266 107 patients (89.1%) were admitted through the ED. A total of 1 906 498 ED revisits were identified. After adjusting for patient demographic and clinical characteristics from the index hospitalization, HRRP implementation was associated with fewer readmissions from the ED, with a difference-in-difference estimate of -0.9 (95% CI, -1.4 to -0.4) percentage points (P < .001), or a 1.4% relative decrease from the 65.8% pre-HRRP readmission rates. Implementation of the HRRP was associated with fewer readmissions at the ED revisit involving clinical presentations for which admission is typically indicated (difference-in-differences estimate, -1.1 [95% CI, -1.6 to -0.6] percentage points; P < .001), or a 1.2% relative decrease from the 93.6% pre-HRRP rate. These results appear to be associated with patients presenting at the ED revisit with congestive heart failure (difference-in-difference estimate, -1.2 [95% CI, -2.0 to -0.4] percentage points; P = .003). These findings suggest that implementation of the HRRP was associated with a lower likelihood of readmission for recently discharged patients presenting to the ED, specifically for congestive heart failure. This highlights the critical role of the ED in readmission reduction under the HRRP and suggests that patient outcomes after HRRP implementation should be further studied.

Hospital Readmissions Reduction Program and Post-Acute Care: Implications for Service Delivery and 30-Day Hospital Readmission

Value-Based Care: An Executive Briefing

ObjectiveTo assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall‐related injuries (FRIs).Data Sources and Study SettingSecondary data from Medicare were used.Study DesignUsing an event study design, among older (≥65) Medicare fee‐for‐service beneficiaries, we assessed changes in 30‐ and 90‐day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus “non‐targeted” (gastrointestinal) conditions. We tested for modification by hospitals with “high‐risk” before HRRP and accounted for potential upcoding. We also explored changes in 30‐day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).Data CollectionNot applicable.Principal FindingsWe identified 1.5 million (522,596 pre‐HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%–20% reductions in 30‐ and 90‐day FRI readmissions for patients with CHF (−0.42 percentage points [ppt], p = 0.02; −1.53 ppt, p < 0.001) and AMI (−0.35, p = 0.047; −0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90‐day FRI readmission for AMI (−1.27 ppt, p = 0.01) and CHF (−0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: −2.43 ppt, p < 0.001; CHF: −8.83 ppt, p < 0.001; pneumonia: −1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: −5.95 ppt, p < 0.001; CHF: −3.19 ppt, p < 0.001; pneumonia: −10.27 ppt, p < 0.001).ConclusionsHRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post‐acute referral patterns that benefit patients at risk for falls.

To support hospital decision makers in their effort to reduce readmissions, the authors of this perspective present employer self-insurance as a potential incentive strategy, in particular for heart failure (HF). In 2010, US health reform identified hospital readmission as a key area for improving care coordination and achieving potential healthcare savings, and enacted the Hospital Readmissions Reduction Program (HRRP). In 2012, the Centers for Medicare and Medicaid Services (CMS) started the implementation of the HRRP by penalizing hospitals with excess 30-day readmission rates. The HRRP targets certain conditions, including HF, which is among the most expensive conditions treated in US hospitals. HF has the highest readmission rate for patients aged 65 and above, and its prevalence is expected to rise to over 8 million people by 2030 due to the aging population. Although the HRRP has been associated with reduced readmission rates, the rate of reduction has slowed. Furthermore, the HRRP may have alarming unintended consequences, such as possible increased mortality among HF patients. As a result, a critical analysis of financial incentives is needed to re-energize these efforts. One opportunity to incentivize readmission reduction is through employer self-insurance. More than half of colleges and universities self-insure the health care coverage they offer to their employees. With these self-insured plans, a hospital could be rewarded through shared savings with a university for readmission reduction. This perspective proposes that the economic case for a hospital to invest in readmission reduction is stronger when a hospital is a part of a self-insured university.

Medicare's Hospital Readmission Reduction Program (HRRP) created clear financial incentives for hospitals to prevent readmissions. Although existing evidence suggests readmission rates have been declining, the direct contribution of this policy to these reductions is unclear. Furthermore, it is unknown whether HRRP has produced unintended effects, including the substitution of outpatient hospital care for readmissions. To determine the effect of HRRP in New York State on both the likelihood of being readmitted and returning to hospital emergency department (ED) care within 30 days of discharge. Difference-in-difference estimation using prepolicy and postpolicy hospital claims data and the proportion of a hospital's inpatient revenue at risk for HRRP penalization to identify policy exposure. Policy effects are estimated using multivariate logistic regressions. We find significant global reductions in readmissions in the postpolicy years, but no evidence of a differential policy effect on patients discharged from hospitals at risk for proportionally larger HRRP penalties in either postpolicy year 1 [adjusted odd ratio (AOR) =1.00, P=0.733] or 2 (AOR=1.01, P=0.315). HRRP did increase the odds of patients from hospitals facing greater financial risk having a 30-day ED visit in both postpolicy years (AOR=1.04, P=0.009 and AOR=1.07, P<0.001). Our findings suggest that while readmissions have decreased in New York State, these declines may not be directly attributable to HRRP penalties. The policy did produce significant potentially unintended effects in the form of greater postdischarge ED utilization among facilities facing proportionally larger penalties.

Unintended Consequences of Hospital Regulation: The Case of the Hospital Readmissions Reduction Program

Introduction: Since implementation of the Hospital Readmission Reduction Program (HRRP), readmission rates have declined among Medicare patients hospitalized with conditions targeted by the policy - myocardial infarction, heart failure, and pneumonia. It is unknown if similar reductions occurred for other insurance types (Medicaid, private). Methods: We conducted a difference-in-difference analysis using the Nationwide Readmission Database. First, we calculated quarterly readmission rates for each insurance type and target condition from 2010 to 2014. Second, we compared how quarterly readmission rates for target conditions changed before (2010-2012) and after HRRP implementation (2012-2014), using changes in readmissions for non-target conditions as controls. The analysis included 3,737,589 patients with target conditions and 31,096,617 patients with non-target conditions. Results: Following HRRP implementation, readmission rates declined for both Medicare and Medicaid patients. Medicaid readmissions for patients with target conditions declined at a significantly greater rate compared to non-target conditions, both in aggregate (change in slope between pre- and post-HRRP periods, -0.044%/quarter [95% CI -0.061; -0.027]), and for each condition: acute myocardial infarction (-0.098 [-0.132; -0.064]), heart failure (-0.030 [-0.055; -0.005]) and pneumonia (-0.079 [-0.107;-0.051]). Composite Medicaid readmission rates, however, remained higher than Medicare. Privately-insured patients had the lowest aggregate readmission rates throughout the study period, with no additional decline after HRRP implementation. Conclusions: The HRRP was associated with reductions in readmissions that extended to the Medicaid population. These findings may reflect the effect of system-wide efforts to reduce readmissions in response to the policy. Medicaid readmission rates, however, remained greater compared to other insurers, and should be considered a focus for future readmission reduction initiatives. Figure. Change in Readmission Rates for All Target Conditions, Across Insurance Types Points represent quarterly risk-adjusted readmission rates. Solid lines were generated from these points through a piecewise linear model. The dashed line separates the pre- and post-HRRP periods.