Link between readmission rates, mortality rates back under scrutiny
| Jan 2, 2019 7:20am
A potential link between higher mortality rates and lower readmission rates raises questions about unintended consequences related to the HRRP.
A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).
Rishi Wadhera, M.D.
(Brigham and Women's Hospital)
The new study, published in JAMA, looked specifically at changes in mortality rates in the 30- and 45-day periods after discharge for patients suffering from heart failure, heart attack or pneumonia.
The 30-day data showed accelerated mortality rates for those with heart failure or pneumonia, though the 45-day data did not.
The HRRP has come under previous scrutiny for potentially raising mortality rates by offering hospitals a perverse incentive to reduce admissions in ways that don’t necessarily meet the patient’s best interest, such as discharging them after emergency room treatment or placing them in a temporary observation unit rather than readmitting them.
In other studies, however, the program’s success at reducing overall readmissions has been hailed as broadly effective.
While the study’s limitations don’t necessarily indicate a causal relationship between the HRRP and the higher mortality rates, it does raise some potential red flags, according to Rishi Wadhera, M.D., a cardiology fellow at Brigham and Women’s Hospital and the study’s lead author.
Wadhera notes that the increase in mortality rates comes amid troubling context . While post-discharge deaths for heart patients with heart failure had already begun to increase in the years prior to the HRRP, the trend actually accelerated after the program was established.
At the same time, the increase in mortality rates for pneumonia patients followed a period of stability in the years prior to the HRRP. Those conditions also saw significant decreases in the number of readmissions after discharge.
Whether hospitals are acting in ways that don’t necessarily benefit patients remains an open question, but Wadhera sees important lessons in the lack of clarity around how the program actually functions.
“I think one of the issues is we really haven’t done a deep dive into how physicians and hospitals have responded to the HRRP,” he said. “All we’ve really observed are the decline in admission rates and we’ve assumed that that was due to improvements in quality of care, but we don’t actually know that.”
Given the potential for unintended harm, Wadhera believes policymakers should slow down and take a more measured approach . “Our takeaway from the findings is that the HRRP should not be expanded to all hospitalized conditions, which is what some policymakers have advocated for recently, and that we should be more cautious before widespread expansion of the program.”
Hospital Readmissions Reduction Program (HRRP)
What is the Hospital Readmissions Reduction Program?
HRRP is a Medicare value-based purchasing program that lowers payments to Inpatient Prospective Payment System (IPPS) hospitals with too many readmissions.
Section 3025 of the Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).
Why is the Hospital Readmissions Reduction Program important?
The HRRP was established to make Americans’ health care better by linking payment to the quality of hospital care. It gives hospitals a strong financial incentive to:
Make their communication and care coordination efforts better.
Work better with patients and caregivers on post-discharge planning.
We’ve included measures of conditions and procedures that make a big difference in the lives of large numbers of people with Medicare. We know that the HRRP, with the Hospital Value Based Purchasing (HVBP) and the Hospital-Acquired Condition (HAC) Reduction Programs, is a major part of how we add quality measurement, transparency, and improvement to value-based payment in the inpatient care setting.
As a part of our Meaningful Measures Framework, we’re looking at the existing measure set as it relates to these other programs. We want to see how we can lower burden and make the programs less complex while we’re giving health care providers incentives to improve patients’ health care quality and value.
Past research has shown that hospital readmission rates are different across the nation. This gives us an opportunity to improve the quality of care and save taxpayer dollars by giving providers incentives to reduce excess readmissions.
What are applicable Hospital Readmissions Reduction Program hospitals?
Applicable hospitals in HRRP are defined in section 1886(d)(1)(
of the Social Security Act.
Maryland hospitals are included under the program in readmission measure calculations, but they’re waived from penalties because they participate in the Maryland All-Payer Model. You can find more information about Maryland hospitals in section 1886(q)(5)(C) of the Social Security Act.
What measures are included in the Hospital Readmissions Reduction Program?
We use the excess readmission ratio (ERR) to gauge hospital performance. The ERR is a measure of a hospital’s relative performance and is the ratio of predicted-to-expected readmissions. We figure an ERR for each of these conditions and procedures that are included in the program:
Acute Myocardial Infarction (AMI)
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure (HF)
Pneumonia
Coronary Artery Bypass Graft (CABG) Surgery
Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)
HRRP doesn’t include the Hospital-Wide All-Cause Readmission (HWR) measure, which is included in the Hospital Inpatient Quality Reporting (IQR) Program.
What counts as a readmission in the Hospital Readmissions Reduction Program?
The 30-day risk standardized readmission measures include:
All-cause unplanned readmissions that happen within 30 days of discharge from the index (i.e., initial) admission.
Patients who are readmitted to the same hospital, or another applicable acute care hospital for any reason.
Readmissions to any applicable acute care hospital are counted, no matter what the principal diagnosis was. The measures don’t include some planned readmissions.
How do we adjust payments under the Hospital Readmissions Reduction Program?
For each eligible hospital, we figure the payment adjustment factor. The payment adjustment factor tells us what percent a hospital’s payment is reduced. We use the adjustment factor for all discharges in the applicable fiscal year, no matter the condition.
You can find more information in the QualityNet Payment Adjustment section.
What is the Review & Corrections period for the Hospital Readmissions Reduction Program?
The 30-day Review and Corrections period is when applicable hospitals can review and correct the accuracy of their ERR calculations for HRRP. Hospitals can’t send in more corrections to the underlying claims data or new claims to the data extract.
Every program year, we let hospitals know the exact dates of the Review and Corrections period.
How will I know if there are changes to the Hospital Readmissions Reduction Program?
Changes to the program happen through rulemaking. These changes are published yearly after a public comment period, with the Inpatient Prospective Payment System /Long-Term Care Hospital Prospective Payment System (IPPS/LTCH PPS) Final Rule.
Where can I get more information about the Hospital Readmissions Reduction Program?
Get more details on the Hospital Readmissions Reduction Program.
https://www.cms.gov/Medicare/Quality-Initiati...ogram.html
The Medicare Hospital Readmission Reduction Program
https://www.kff.org/.../aiming-for-fewer-hosp...al-readm...
Mar 10, 2017 - The first five years of the Hospital Readmission Reduction Program. The HRRP was established by a provision in the Affordable Care Act (ACA) requiring Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare.
Study links financial penalties to lower readmission rates
Federal penalties do lead to lower readmission rates, a new study has found.
The research, published in the Journal of the American Medical Association, found that hospitals penalized as part of the Hospital Readmission Reduction Program (HRRP) reduced 30-day readmissions by more significant margins than hospitals that weren't penalized. The study team examined data from more than 48 million hospitalizations of Medicare beneficiaries at nearly 3,500 U.S. hospitals recorded between January 2008 and June 2015.
The penalized hospitals saw significant reductions in readmissions for targeted conditions like heart attack, pneumonia and heart failure. Readmission rates were stable for both types of hospitals between 2008 and 2010, when HRRP was first introduced, but once the program was launched, rates for both target and nontarget conditions dropped far more rapidly at hospitals that were later penalized, according to the study.
The Centers for Medicare & Medicaid Services penalized half of U.S. hospitals for readmission rates this year, and many of the hospitals penalized are large, teaching hospitals that are likely to admit Medicaid or Medicare patients. The penalties are controversial, and major professional organizations like the American Hospital Association have questioned the methods used to assess the data.
Nihar R. Desai, M.D., assistant professor of medicine at Yale School of Medicine and the study’s lead author, said in an announcement of the findings that the penalties likely shaped hospital response to excessive readmissions.
"We found that hospitals that were subject to penalties under HRRP had more significant reductions in readmissions than hospitals that were not penalized," he said. "In addition, hospitals that were subject to penalty also seemed to focus their efforts on reducing readmissions for conditions that were the basis of the penalty. In contrast, hospitals that weren't penalized seemed to reduce readmissions across all conditions."
A separate study on the effectiveness of HRRP penalties also concluded that hospitals with the worst performance before the passage of the Affordable Care Act improved most after the HRRP was implemented. The research, published in Annals of Internal Medicine, analyzed discharge data for more than 15 million Medicare patients hospitalized between 2000 and 2013 and found that additional readmissions were averted at hospitals in all performance levels measured after the establishment of the HRRP.
https://www.fiercehealthcare.com/hospitals-he...r-scrutiny
https://www.fiercehealthcare.com/finance/stud...admissions
| Jan 2, 2019 7:20am
A potential link between higher mortality rates and lower readmission rates raises questions about unintended consequences related to the HRRP.
A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).
Rishi Wadhera, M.D.
(Brigham and Women's Hospital)
The new study, published in JAMA, looked specifically at changes in mortality rates in the 30- and 45-day periods after discharge for patients suffering from heart failure, heart attack or pneumonia.
The 30-day data showed accelerated mortality rates for those with heart failure or pneumonia, though the 45-day data did not.
The HRRP has come under previous scrutiny for potentially raising mortality rates by offering hospitals a perverse incentive to reduce admissions in ways that don’t necessarily meet the patient’s best interest, such as discharging them after emergency room treatment or placing them in a temporary observation unit rather than readmitting them.
In other studies, however, the program’s success at reducing overall readmissions has been hailed as broadly effective.
While the study’s limitations don’t necessarily indicate a causal relationship between the HRRP and the higher mortality rates, it does raise some potential red flags, according to Rishi Wadhera, M.D., a cardiology fellow at Brigham and Women’s Hospital and the study’s lead author.
Wadhera notes that the increase in mortality rates comes amid troubling context . While post-discharge deaths for heart patients with heart failure had already begun to increase in the years prior to the HRRP, the trend actually accelerated after the program was established.
At the same time, the increase in mortality rates for pneumonia patients followed a period of stability in the years prior to the HRRP. Those conditions also saw significant decreases in the number of readmissions after discharge.
Whether hospitals are acting in ways that don’t necessarily benefit patients remains an open question, but Wadhera sees important lessons in the lack of clarity around how the program actually functions.
“I think one of the issues is we really haven’t done a deep dive into how physicians and hospitals have responded to the HRRP,” he said. “All we’ve really observed are the decline in admission rates and we’ve assumed that that was due to improvements in quality of care, but we don’t actually know that.”
Given the potential for unintended harm, Wadhera believes policymakers should slow down and take a more measured approach . “Our takeaway from the findings is that the HRRP should not be expanded to all hospitalized conditions, which is what some policymakers have advocated for recently, and that we should be more cautious before widespread expansion of the program.”
Hospital Readmissions Reduction Program (HRRP)
What is the Hospital Readmissions Reduction Program?
HRRP is a Medicare value-based purchasing program that lowers payments to Inpatient Prospective Payment System (IPPS) hospitals with too many readmissions.
Section 3025 of the Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).
Why is the Hospital Readmissions Reduction Program important?
The HRRP was established to make Americans’ health care better by linking payment to the quality of hospital care. It gives hospitals a strong financial incentive to:
Make their communication and care coordination efforts better.
Work better with patients and caregivers on post-discharge planning.
We’ve included measures of conditions and procedures that make a big difference in the lives of large numbers of people with Medicare. We know that the HRRP, with the Hospital Value Based Purchasing (HVBP) and the Hospital-Acquired Condition (HAC) Reduction Programs, is a major part of how we add quality measurement, transparency, and improvement to value-based payment in the inpatient care setting.
As a part of our Meaningful Measures Framework, we’re looking at the existing measure set as it relates to these other programs. We want to see how we can lower burden and make the programs less complex while we’re giving health care providers incentives to improve patients’ health care quality and value.
Past research has shown that hospital readmission rates are different across the nation. This gives us an opportunity to improve the quality of care and save taxpayer dollars by giving providers incentives to reduce excess readmissions.
What are applicable Hospital Readmissions Reduction Program hospitals?
Applicable hospitals in HRRP are defined in section 1886(d)(1)(
of the Social Security Act. Maryland hospitals are included under the program in readmission measure calculations, but they’re waived from penalties because they participate in the Maryland All-Payer Model. You can find more information about Maryland hospitals in section 1886(q)(5)(C) of the Social Security Act.
What measures are included in the Hospital Readmissions Reduction Program?
We use the excess readmission ratio (ERR) to gauge hospital performance. The ERR is a measure of a hospital’s relative performance and is the ratio of predicted-to-expected readmissions. We figure an ERR for each of these conditions and procedures that are included in the program:
Acute Myocardial Infarction (AMI)
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure (HF)
Pneumonia
Coronary Artery Bypass Graft (CABG) Surgery
Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)
HRRP doesn’t include the Hospital-Wide All-Cause Readmission (HWR) measure, which is included in the Hospital Inpatient Quality Reporting (IQR) Program.
What counts as a readmission in the Hospital Readmissions Reduction Program?
The 30-day risk standardized readmission measures include:
All-cause unplanned readmissions that happen within 30 days of discharge from the index (i.e., initial) admission.
Patients who are readmitted to the same hospital, or another applicable acute care hospital for any reason.
Readmissions to any applicable acute care hospital are counted, no matter what the principal diagnosis was. The measures don’t include some planned readmissions.
How do we adjust payments under the Hospital Readmissions Reduction Program?
For each eligible hospital, we figure the payment adjustment factor. The payment adjustment factor tells us what percent a hospital’s payment is reduced. We use the adjustment factor for all discharges in the applicable fiscal year, no matter the condition.
You can find more information in the QualityNet Payment Adjustment section.
What is the Review & Corrections period for the Hospital Readmissions Reduction Program?
The 30-day Review and Corrections period is when applicable hospitals can review and correct the accuracy of their ERR calculations for HRRP. Hospitals can’t send in more corrections to the underlying claims data or new claims to the data extract.
Every program year, we let hospitals know the exact dates of the Review and Corrections period.
How will I know if there are changes to the Hospital Readmissions Reduction Program?
Changes to the program happen through rulemaking. These changes are published yearly after a public comment period, with the Inpatient Prospective Payment System /Long-Term Care Hospital Prospective Payment System (IPPS/LTCH PPS) Final Rule.
Where can I get more information about the Hospital Readmissions Reduction Program?
Get more details on the Hospital Readmissions Reduction Program.
https://www.cms.gov/Medicare/Quality-Initiati...ogram.html
The Medicare Hospital Readmission Reduction Program
https://www.kff.org/.../aiming-for-fewer-hosp...al-readm...
Mar 10, 2017 - The first five years of the Hospital Readmission Reduction Program. The HRRP was established by a provision in the Affordable Care Act (ACA) requiring Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare.
Study links financial penalties to lower readmission rates
Federal penalties do lead to lower readmission rates, a new study has found.
The research, published in the Journal of the American Medical Association, found that hospitals penalized as part of the Hospital Readmission Reduction Program (HRRP) reduced 30-day readmissions by more significant margins than hospitals that weren't penalized. The study team examined data from more than 48 million hospitalizations of Medicare beneficiaries at nearly 3,500 U.S. hospitals recorded between January 2008 and June 2015.
The penalized hospitals saw significant reductions in readmissions for targeted conditions like heart attack, pneumonia and heart failure. Readmission rates were stable for both types of hospitals between 2008 and 2010, when HRRP was first introduced, but once the program was launched, rates for both target and nontarget conditions dropped far more rapidly at hospitals that were later penalized, according to the study.
The Centers for Medicare & Medicaid Services penalized half of U.S. hospitals for readmission rates this year, and many of the hospitals penalized are large, teaching hospitals that are likely to admit Medicaid or Medicare patients. The penalties are controversial, and major professional organizations like the American Hospital Association have questioned the methods used to assess the data.
Nihar R. Desai, M.D., assistant professor of medicine at Yale School of Medicine and the study’s lead author, said in an announcement of the findings that the penalties likely shaped hospital response to excessive readmissions.
"We found that hospitals that were subject to penalties under HRRP had more significant reductions in readmissions than hospitals that were not penalized," he said. "In addition, hospitals that were subject to penalty also seemed to focus their efforts on reducing readmissions for conditions that were the basis of the penalty. In contrast, hospitals that weren't penalized seemed to reduce readmissions across all conditions."
A separate study on the effectiveness of HRRP penalties also concluded that hospitals with the worst performance before the passage of the Affordable Care Act improved most after the HRRP was implemented. The research, published in Annals of Internal Medicine, analyzed discharge data for more than 15 million Medicare patients hospitalized between 2000 and 2013 and found that additional readmissions were averted at hospitals in all performance levels measured after the establishment of the HRRP.
https://www.fiercehealthcare.com/hospitals-he...r-scrutiny
https://www.fiercehealthcare.com/finance/stud...admissions
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