Abstract
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.
Highlights
The Hospital Readmissions Reduction Program (HRRP) of the Centers for Medicare and Medicaid Services (CMS) began October 2012 in an effort to decrease readmissions within 30 days of hospitalization.[1,2,3] As part of the Patient Protection and Affordable Care Act, the HRRP has evolved as a national health policy, progressively increasing its maximum penalty from 1% to 3% of total Medicare inpatient payments based on excess readmissions.[4,5,6] the policy initially covered readmissions following 3 common medical conditions, the policy expanded in 2014 to include chronic obstructive pulmonary disease and its first surgical procedures: elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).[1]
excess readmission ratio (ERR) and Arthroplasty Volume We identified 60 663 Medicare patients who underwent elective THA and TKA across 143 hospitals in Florida during 2012 and 2013, the 2 most recent lead-in years used to calculate the 2015 HRRP penalties
We found that the Medicare unadjusted 30-day arthroplasty readmission rate in Florida hospitals was 4.9%, accounting for 2991 patients
Summary
The Hospital Readmissions Reduction Program (HRRP) of the Centers for Medicare and Medicaid Services (CMS) began October 2012 in an effort to decrease readmissions within 30 days of hospitalization.[1,2,3] As part of the Patient Protection and Affordable Care Act, the HRRP has evolved as a national health policy, progressively increasing its maximum penalty from 1% to 3% of total Medicare inpatient payments based on excess readmissions.[4,5,6] the policy initially covered readmissions following 3 common medical conditions (acute myocardial infarction, heart failure, and pneumonia), the policy expanded in 2014 to include chronic obstructive pulmonary disease and its first surgical procedures: elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).[1]. Safety-net and teaching hospitals are more likely to be penalized by the HRRP despite having better mortality outcomes.[10,11,12,13] In addition, patient characteristics (eg, sociodemographic characteristics and performance status) not included in the case-mix adjustments of the policy may contribute to readmissions, leaving some hospitals unfairly penalized.[14] For targeted medical conditions, changes in documentation standards may have inflated the reported association of the program with reducing readmission rates.[15] This has spurred concern regarding similar dynamics in surgical procedures and future implementation of the HRRP
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