The Hospital Readmissions Reduction Program

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ª 2019 THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. PUBLISHED BY ELSEVIER. ALL RIGHTS RESERVED.

STATE-OF-THE-ART PAPER

The Hospital Readmissions Reduction Program Nationwide Perspectives and Recommendations Mitchell A. Psotka, MD, PHD,a Gregg C. Fonarow, MD,b Larry A. Allen, MD, MHS,c Karen E. Joynt Maddox, MD, MPH,d Mona Fiuzat, PHARMD,e Paul Heidenreich, MD, MS,f Adrian F. Hernandez, MD, MHS,g Marvin A. Konstam, MD,h Clyde W. Yancy, MD, MSC,i Christopher M. O’Connor, MDa

ABSTRACT The mandatory federal pay-for-performance Hospital Readmissions Reduction Program (HRRP) was created to decrease 30-day hospital readmissions by instituting accountability and stimulating quality care and coordination, particularly during care transitions. The HRRP has changed the landscape of hospital readmissions and reimbursement within the United States by imposing substantial Medicare payment penalties on hospitals with higher-than-expected readmission rates. However, the HRRP has been controversial since its inception, particularly in the field of heart failure. Proponents argue that it has reduced national readmission rates, in part by raising awareness and investment in mechanisms to better assist patients during discharge and transitions; opponents contend that it unfairly penalizes hospitals for issues beyond their control, has unintended negative consequences due to incentivizing readmission over survival, that it encourages “gaming” the system, was not tested before implementation, and that it does not specify how hospitals can improve their performance. This paper incorporates the diverse, nuanced, and sometimes divergent interpretations presented during a multifaceted expert clinician discussion regarding the HRRP and heart failure; in cases in which consensus opinions were achieved, they are presented, including regarding potential new iterations of the HRRP for the future. Potential improvements include more comprehensive incorporation of outcomes into the HRRP measure and better risk adjustment to improve equality and fairness. (J Am Coll Cardiol HF 2019;-:-–-) © 2019 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

From the aInova Heart and Vascular Institute, Falls Church, Virginia; bAhmanson–UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California; cDivision of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; dWashington University School of Medicine, St. Louis, Missouri; eDepartment of Medicine, Duke University School of Medicine, Durham, North Carolina; fMedical Service, VA Palo Alto Health Care System, Palo Alto, California; g

Duke Clinical Research Institute, Durham, North Carolina; hCardioVascular Center, Tufts Medical Center, Boston, Massachusetts;

and the iDivision of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Dr. Psotka has received consulting fees from Amgen, Cytokinetics, and Roivant. Dr Fonarow has received consulting fees from Abbott, Amgen, Bayer, Janssen, Medtronic, and Novartis. Dr. Allen has received research support from the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and the American Heart Association; and consulting fees from Boston Scientific and Cytokinetics. Dr. Joynt Maddox has received research support from the National Heart, Lung, and Blood Institute (K23HL109177-03); and is a former employee of the U.S. Department of Health and Human Services, where she continues work on a limited basis as a contractor. Dr. Hernandez has received research support from AstraZeneca, Bayer, Luitpold, GlaxoSmithKline, Merck, Novartis, Portola Pharmaceuticals, and Verily; and honoraria from Amgen, Bayer, Boehringer Ingelheim, Boston Scientific, MyoKardia, Novartis, and Sanofi. Dr. O’Connor has received research funding from and has served as a consultant to ResMed, Merck, and Bristol-Myers Squibb; has served as a consultant to Stealth Peptides; and is a co-owner of BisCardia. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. John Teerlink, MD, served as Guest Editor for this paper. Manuscript received January 2, 2019; revised manuscript received July 8, 2019, accepted July 29, 2019.

ISSN 2213-1779/$36.00

https://doi.org/10.1016/j.jchf.2019.07.012

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ABBREVIATIONS AND ACRONYMS

A

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Hospital Readmissions Reduction Program

merican health care costs continue

However, since its inception, the HRRP has been

to soar, but clinical outcomes and

controversial, particularly in the field of HF. Pro-

other quality measures remain sub-

ponents argue that it has successfully reduced na-

optimal (1). The federal health insurance

tional readmission rates, in part by raising awareness

program Medicare covers 57 million Ameri-

and investment in mechanisms to better assist pa-

cans and annually accounts for >15% of US

tients during discharge and transitions; opponents

government spending, or 3% of the gross

contend that it unfairly penalizes hospitals for issues

domestic product (2). In this context, hospi-

beyond their control, has unintended negative con-

tal readmissions are a frequent and costly

sequences due to incentivizing readmission avoidance

purchasing

adverse event for patients, but risk varies

over patient survival, that it encourages “gaming” the

MedPAC = Medicare Payment

between institutions and correlates with

system by up-coding claims, that it was not tested

Advisory Commission

additional negative clinical outcomes (3,4).

before implementation, that it does not specify how

RSMR = risk-standardized

The 2007 Medicare Payment Advisory Com-

hospitals can meaningfully improve their perfor-

mortality rates

mission (MedPAC), a group of non–heart

mance, and that punitive measures may be unlikely to

RSRR = risk-standardized

failure (HF) specialist political appointees

produce process improvements. Six years after the

CMS = Centers for Medicare & Medicaid Services

FFS = fee-for-service HF = heart failure HRRP = Hospital Readmissions Reduction Program

HVBP = hospital value-based

readmission rates

that may not necessarily possess subject

initial implementation, data from multiple sources

area expertise but advises Congress on Medicare,

have been used to evaluate the HRRP but have reached

estimated that 13.3% of all Medicare beneficiaries

discrepant conclusions about its efficacy, conse-

experience

readmission

quences, impact on equity, and appropriate pathways

within 30 days of discharge, suggesting that read-

forward. The current paper incorporates the diverse,

missions may be targeted to enhance health care

nuanced, and sometimes divergent interpretations

provision (5). Following this logic, in 2009, the Cen-

presented during a multifaceted expert discussion

a

preventable

hospital

ters for Medicare & Medicaid Services (CMS) started

regarding the HRRP and HF (Online Appendix A); in

publicly reporting 30-day hospital risk-standardized

cases in which consensus opinions were achieved,

readmission rates (RSRRs) on its Hospital Compare

they are presented, including regarding potential new

website; however, RSRRs initially showed no or a

iterations of the HRRP for the future.

slight decline (6,7). The mandatory federal pay-for-performance Hos-

GUIDING PRINCIPLES

pital Readmissions Reduction Program (HRRP) was created under the 2010 Patient Protection and

The primary goal of all endeavors to augment health

Affordable Care Act to decrease 30-day hospital

care quality should be to improve health in a patient-

readmissions; readmissions reporting started in 2010,

centered and just manner. Thus, the efficacy and

and the penalty phase began in 2012 (8) (Table 1).

safety of any broad health care policy such as the

Hospitals with higher-than-expected 30-day all-cause

HRRP need to be rigorously ascertained, as straight-

Medicare fee-for-service (FFS) readmissions after

forward rules can have intended and inadvertent re-

initial hospitalization for HF, acute myocardial

sponses

infarction, and pneumonia, as determined by using a

therapeutics. However, unlike many medical or pub-

CMS claims-based risk standardization algorithm,

lic health interventions, the HRRP was legislated by

were penalized up to 1% of their total inpatient

the US government; this legal permanence requires

Medicare payments. The goal was to institute

that recommended changes must either work to

accountability and stimulate quality care and coor-

adjust the programmatic function within current legal

dination,

boundaries or request legislative amendment. In

particularly

during

care

transitions,

comparable

because

the

to

new

HRRP

was

pharmaceutical

although the legislation did not recommend specific

addition,

interventions or process changes. In subsequent

simultaneously nationwide, it is not possible to

implemented

years, the maximum penalty rose to 3% of total

completely and assuredly disentangle specific pro-

Medicare payments and expanded to include chronic

grammatic effects from secular interacting health and

obstructive pulmonary disease, total hip or knee

population trends occurring contemporaneously; the

arthroplasty, and coronary artery bypass graft. With

evidence in support and critical of the HRRP is thus

increasing numbers of target conditions included,

observational and limited by comparison only to

79% of Medicare-participating hospitals have been

historic controls. Finally, in this context, the authors

penalized, saving Medicare millions of dollars (9)

acknowledge that reasonable people can disagree in

(Table 2). The HRRP has changed the landscape of

the evaluation of the HRRP and its effects as well as

hospital readmissions and reimbursement within the

recommendations on how the program may be

United States.

improved. The following discussion acknowledges

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HRRP-targeted

T A B L E 1 Timeline of the HRRP

conditions

have

declined

more

rapidly than for nontargeted conditions (11,16). The

2007 – CMS begins public reporting of hospital RSMRs

HRRP thereby has directly reduced Medicare expen-

2007 – CMS commissions hospital RSRRs

ditures substantially, through penalties assessed to

2009 – CMS begins public reporting of hospital RSRRs 2010 – Passage of the Patient Protection and Affordable Care Act creates the HRRP 2011 – CMS includes Veterans Affairs hospitals in public reporting of RSMR and RSRR 2012 – Initial implementation of the HRRP penalties, from 2009–2011 RSRR data

hospitals and by decreasing expenditures for patients rehospitalized early after index admission, with estimates increasing from $290 million in 2013 to $564 million in 2018 (9). The HRRP goal of preventing avoidable hospital

2013 – RSRR modified to include only unplanned hospital readmission rates

readmissions by improving quality and transitions of

2019 – CMS includes stratification by proportion of Medicaid patients in risk adjustment

A national survey of hospital executives found that

care seems to have been at least partially successful. the HRRP affected prioritization of hospital admis-

CMS ¼ Centers for Medicare & Medicaid Services; HRRP ¼ Hospital Readmissions Reduction Program; RSMRs ¼ risk-standardized mortality rates; RSRRs ¼ risk standardized readmission rates.

sions and suggested that hospitals and health systems expended considerable resources to improve the discharge and transition process (20,21). The HRRP

these areas of disagreement as well as the gains and limitations of the HRRP 30-day metric and its ramifications, and seeks to establish tenable ways to sufficiently remodel the program to best improve health for patients.

spurred internal readmissions tracking systems with increased Chief Medical Officer awareness and direct involvement, use of dedicated discharge planners, and frequent post-discharge calls to patients. A positive correlation between hospitals with superior post-discharge readmission rates and better perfor-

PROGRAM EFFECTIVENESS

mance on other quality metrics provide additional evidence

Based on readmission rates from administrative claims data alone, the program seemed to be effica-

that

the

HRRP

has

spurred

quality

improvement. Nevertheless,

recent

data

suggest

that

the

cious. Medicare hospital RSRRs for both nontargeted

observed declines in national readmission rates

and targeted conditions including HF reportedly

reflect changes in coding and patient management

decreased considerably since HRRP implementation

rather than quality improvement alone (4,22–24).

(10–18). Although the exact rates vary depending on

Hospital RSRRs can be reduced by increasing admin-

the population and analysis, raw all-cause hospital

istrative coding of patient risk, declining or delaying

readmissions for target conditions within Medicare

appropriate

FFS decreased from 17.9% to 15.8% between 2008 and

observation stays (billed as outpatient services), or

2016 (16). Whereas raw readmissions of Medicare FFS

increasing emergency department discharges.

admissions,

treating

admissions

as

patients with HF increased between 1993 and 2006,

Coded inpatient complexity has increased over

they declined from w23.8% to 20.6% between 2008

the past decade, suggesting that administrative

and 2016, with similar decreases in the RSRR (Central

coding changes may be responsible for some of the

Illustration, Table 3) (19). Furthermore, penalized

RSRR reduction (25,26). However, greater patient

hospitals reported greater reductions in RSRR than

complexity may be due to truly increased illness

those that were not penalized, and RSRRs for

severity;

tandem

declines

in

raw

and

T A B L E 2 Annual Impact of the Hospital Readmissions Reduction Program

Measurement period Target diagnoses Hospitals penalized, %* Mean hospital penalty, % Estimated Medicare savings through penalties

2013

2014

2015

2016

2017

2018

2009–2011

2010–2012

2011–2013

2012–2014

2013–2015

2014–2016

AMI, HF, PNA

AMI, HF, PNA

AMI, HF, PNA, COPD, TKA/THA

AMI, HF, PNA, COPD, TKA/THA

AMI, HF, PNA, COPD, TKA/THA, CABG

AMI, HF, PNA, COPD, TKA/THA, CABG

64

66

78

78

79

79

–0.42

–0.38

–0.63

–0.61

–0.74

–0.73

$290 million

$227 million

$428 million

$420 million

$528 million

$564 million

*Proportion of hospitals penalized during the listed fiscal year. Adapted from the Kaiser Family Foundation (9). AMI ¼ acute myocardial infarction; COPD ¼ chronic obstructive pulmonary disease; CABG ¼ coronary artery bypass graft; HF ¼ heart failure; PNA ¼ pneumonia; TKA ¼ total knee arthroplasty; THA ¼ total hip arthroplasty.

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C E N T R A L IL LU ST R A T I O N Assessments of Hospital Readmissions Reduction Program Impact

A

MedPAC Reported Raw and Risk-Standardized Heart Failure Outcomes 30

Percent at 30-Days

25 20 15 10 5 0

HRRP Penalty Announced 2008

2009

HRRP Penalty Implemented

2010 RRR

B

2011

2012 Year

RSRR

2013 RMR

2014

2015

2016

RSMR

Independent Reported Raw and Adjusted Heart Failure Outcomes 25 20 Percent at 30-Days

4

15 10 5 0

HRRP Penalty Announced 2005-2007

HRRP Penalty Implemented

2007-2010 2010-2012 Time Period

RRR

IPW ARR

RMR

2012-2015 IPW AMR

Psotka, M.A. et al. J Am Coll Cardiol HF. 2019;-(-):-–-.

(A) Reported raw and risk standardized 30-day post-discharge Heart Failure Readmissions and in-hospital plus 30-day post-discharge mortality from the Medicare Payment Advisory Commission (MedPAC). Graphical representation of the raw and risk-adjusted 30-day heart failure hospital readmission and in-hospital plus 30-day post-discharge mortality rates in the years proceeding announcement of the Hospital Readmissions Reduction Program (HRRP) (before 2010), between passage of the Patient Protection and Affordable Care Act announcing the HRRP, and after implementation of the HRRP penalties in 2012. Adapted from the 2018 Medicare Payment Advisory Commission Report to Congress (16). (B) Independent assessment of trends in raw and inverse probability-weighted (IPW)-adjusted 30-day post-discharge readmissions and mortality for patients with heart failure from Medicare feefor-service claims data. Graphical representation of independently assessed raw and IPW 30-day heart failure post-discharge readmission and mortality. Adapted from Wadhera et al. (36). AMR ¼ adjusted mortality rate; ARR ¼ adjusted readmission rate; RMR ¼ raw mortality rate; RRR ¼ raw readmission rate; RSMR ¼ risk-standardized mortality rate; RSRR ¼ risk-standardized readmission rate.

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Hospital Readmissions Reduction Program

T A B L E 3 Reported Impact of the HRRP on Heart Failure Readmissions and Mortality

Years Included

GWTG-HF Linked 2006–2010 and to Medicare FFS 2012–2014

Analyzed Patients

115,245 hospitalizations, 416 hospitals

Medicare FFS

2008–2014

5% Sample Medicare FFS

2010–2012

207,687 hospitalizations

Medicare FFS

2008–2016

Not explicitly stated

30-Day Readmissions 30-Day Readmissions Before HRRP After HRRP

RSRR 20.0%

2,962,554 hospitalizations, RSRR 23.4%–23.5% 5,016 hospitals –

Mortality Before HRRP

Mortality After HRRP

RSRR 18.4%

Raw 7.2% 30-day Raw 31.3% 1-yr

Raw 8.6% 30-day Raw 36.3% 1-yr

33

RSRR 21.4%–22.5%

Raw 7.9%-8.4% 30-day

Raw 8.8%-9.2% 30-day

35

–

Raw 27.8% 1-yr

Raw 31.1% 1-yr

61

Raw 23.6%–23.8% Raw 20.6%–21.9% Raw 11.1%-11.4% 30-day Raw 11.9%-12.4% 30-day RSRR 24.0%–24.8% RSRR 20.1%–21.9% RSMR 12.2%-13.6% 30-day RSMR 9.4%-11.1% 30-day

Ref. #

16

Passage of the Patient Protection and Affordable Care Act occurred April 1, 2010, and the HRRP was implemented October 1, 2012. Thus, for available data, “Before HRRP” indicates up to and including 2010, and “After HRRP” indicates from 2012 onward. FFS ¼ fee-for-service; GWTG-HF ¼ Get with The Guidelines–Heart Failure Registry; other abbreviations as in Table 1.

risk-standardized readmission rates suggest that

conditions have increased, in 1 report from 2.6% to

improved RSRRs do not wholly derive from up-

4.7% since HRRP initiation, and emergency depart-

coded risk (Central Illustration) (16). In addition,

ment visits have risen 50% (10,16). When increased

between 2010 and 2016, the absolute number of

observation stays and emergency department visits

Medicare initial admissions per capita fell by 17%,

are accounted for, the post-HRRP decline in RSRRs

and the per capita HF admissions fell by 14%.

drops from 3.9% to 0.7%; thus, a large portion of the

Decreased initial admissions for healthier patients

decline in RSRRs reflects changes in clinical behavior

may partially explain why the modern admitted

to divert patients to observation status or discharge

case mix has greater illness severity. Nonetheless,

rather than enhanced care transitions (16). Although

admission of patients with greater intrinsic risk may

some of these decisions may reflect inappropriate

be expected to increase inpatient mortality, yet in-

withholding of care, some of these alternative stra-

hospital survival has increased (27). Whether this

tegies may be appropriate; patients prefer discharge

trend is due to competing improvements in hospital

home if admission is unnecessary. In addition, the

care for patients with HF is unclear.

rates of emergency department use and observation alternatively

stays were increasing at similar rates before the

reflect a shift of care from the inpatient to outpatient

announcement and enactment of the HRRP, which

setting without curbing post-discharge events. If

implies that additional and distinct incentives from

improved care transitions and disease management

the HRRP may motivate this practice (Table 4).

Reduced

readmission

rates

may

were responsible for HRRP-associated declines in RSRRs for HF, unplanned visits within 30 days after

IMPACT ON MORTALITY

discharge should be decreased overall, inclusive of observation stays and emergency department pre-

Generally, hospitals with higher readmission rates

sentations. However, observation stays for targeted

tend to have lower mortality (28–30). By incentivizing

T A B L E 4 Crude Rates of Change for Post-Hospitalization Outcomes Associated With Implementation of the HRRP Calculated From MedPAC

Before HRRP 2008–2010

Announcement of HRRP 2010–2012

Implementation of HRRP 2012–2016

Raw 30-day HF readmission rate

Y 0.1% per yr

Y 0.4% per yr

Y 0.5% per yr

Risk-standardized 30-day HF readmission rate

Y 0.4% per yr

Y 0.6% per yr

Y 0.6% per yr

Raw total ED visits per hospital discharge

[ 0.1% per yr

[ 0.8% per yr

[ 0.1% per yr

Raw total observation visits per hospital discharge

[ 0.1% per yr

[ 0.2% per yr

[ 0.1% per yr

Raw 30-day HF (including in-hospital) mortality rates

[ 0.1% per yr

[ 0.2% per yr

0.0% per yr

Risk-standardized 30-day HF mortality rates (including in-hospital mortality)*

Y 0.7% per yr

Y 0.5% per yr

Y 0.4% per yr

Crude rates of change were calculated by subtracting the ending rate in percent from the beginning rate for each time period and dividing by the number of years. Passage of the Patient Protection and Affordable Care Act occurred April 1, 2010 and the HRRP was implemented October 1, 2012. The Patient Protection and Affordable Care Act contained the HRRP. *Utilized statistical model is unreleased. Calculated from data in the Medicare Payment Advisory Commission (MedPAC) 2018 Report to Congress (16). ED ¼ emergency department; other abbreviations as in Tables 1 and 2.

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T A B L E 5 Independently Calculated Crude Changes in Post-Hospitalization Outcomes Associated With Implementation of the HRRP

Before HRRP 2007–2010

Announcement of HRRP 2010–2012

Implementation of HRRP 2012–2016

Raw 30-day readmission rate

[0.3%

Y0.4%

Y0.7%

IPW-adjusted 30-day readmission rate

[0.4%

Y0.8%

Y0.6%

Raw 30-day death without readmission rate

[0.4%

[0.6%

[0.6%

IPW adjusted 30-day death without readmission rate

[0.3%

[0.5%

[0.5%

Raw 30-day mortality rates

[0.5%

[0.6%

[0.7%

IPW-adjusted 30-day mortality rates

[0.3%

[0.5%

[0.5%

Crude rates of change calculated by subtracting the average rate in each period from the average rate in the prior period; the period including 2005–2007 was used as the period before 2007–2010. Passage of the Patient Protection and Affordable Care Act occurred April 1, 2010, and the Hospital Readmissions Reduction Program (HRRP) was implemented October 1, 2012. The Patient Protection and Affordable Care Act contained the HRRP. Calculated from data Wadhera et al. (36). IPW ¼ inverse probability-weighted.

hospitals to focus on readmissions, the HRRP could

positive correlation between hospitals with improved

unintentionally increase mortality because its read-

RSRRs and improved RSMRs, suggesting that within-

mission penalties are greater in severity than those

hospital improvement in readmissions is linked with

for mortality metrics such as hospital value-based

better survival (35). The same weak correlation was

purchasing (HVBP) (31,32). This misalignment may

seen in the independent MedPAC report to Congress

encourage clinicians to inappropriately discharge

(16). In addition, although the MedPAC analysis con-

patients presenting for potential readmission, leading

cedes a steadily climbing raw HF mortality rate, it

to higher rates of death. Although no sufficiently

contends the rise began before HRRP initiation, cor-

granular evidence exists to disentangle these poten-

relates with increasing illness severity for the pa-

tial effects or their root causes, mortality has risen for

tients who are admitted, and is offset by falling raw

patients with HF since the implementation of the

and adjusted readmission rates and RSMRs for all

HRRP.

targeted conditions (Central Illustration, Table 4).

Data from the Get With The Guidelines–Heart Failure

registry

independent

assessment

using

increased 30-day and 1-year risk-standardized mor-

discharge HF mortality associated with both HRRP

tality rates (RSMRs) temporally correlated with

announcement and implementation, despite adjust-

implementation of the HRRP (33). Analyses of Medi-

ment for case mix (Table 5) (36). The increase in 30-

care

data

day mortality for patients with HF seems to have

described a rise in RSMRs since the time of HRRP

started between 2006 and 2008; mortality was

reported

Medicare

an

Medicare FFS claims data found increases in post-

publicly

to

Nonetheless,

reported

and

linked

hospital-level

implementation when evaluated either by using

steadily decreasing previously (16,19,27). Although

30 days from admission or from hospital discharge

correlation of changes in re-hospitalization and mor-

(27,34).

tality before and after HRRP implementation may be

However, findings have been complex. Analysis of

confounded by distinct secular trends and by altered

the full Medicare FFS dataset acknowledged a tem-

coding of factors used in risk standardization, the

poral increase in 30- and 90-day post-discharge

underlying etiology of the increased raw mortality

RSMRs for patients with HF but also found a small

rates for HF remains incompletely explained and merits ongoing investigation.

T A B L E 6 Socioeconomic and Health Disadvantage in the Medicare Population for

IMPACT ON EQUITY

Patients With Medicaid

The HRRP has disproportionately penalized the

Medicare With Medicaid

Medicare Without Medicaid

<10,000

10,000–>130,000

Percentage of Medicare, %

15

85

Heart failure prevalence, %

17.3

12.8

Depression prevalence, %

9.8

6.2

Readmission for heart failure (odds ratio)

1.24

1.0

<0.05

Risk-standardized readmission for heart failure (odds ratio)

1.13

1.0

<0.05

Annual income, $

Adapted from United States Department of Health and Human Services Report to Congress (40).

p Value

safety-net hospitals that serve greater proportions of socioeconomically

disadvantaged

patient

pop-

ulations, which could exacerbate disparities in health outcomes (9,37–39). Safety-net hospitals have RSRRs 2.1% greater than non–safety-net hospitals, leading to higher financial penalties under the HRRP. Although a portion of the higher RSRRs seen at safety-net hospitals may be due to under-resourcing and provision of fewer interventions to curtail readmissions

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T A B L E 7 Recommendations of the Panel

1. Improve the readmissions measure:  Include all acute post-discharge care, including observation stays and ED visits, to accurately reflect patients seeking care after discharge  Incorporate the HRRP (readmission) and HVBP (mortality) into a single program, with greater weighting for mortality relative to admission  Consider a more comprehensive post-discharge composite outcomes measure, including patient-reported outcomes, with oversight from patients and patient representatives  Research the potential implications of alternative iterations of the HRRP, including the use of a single outcomes metric, utilizing home time or excess days in acute care, the transition to fixed versus relative performance targets, or implementing different time frames such as a graduated penalty that wanes with follow-up time  Research the underlying causes of increasing absolute mortality after hospital admission for HF 2. Improve equity under the readmissions measure:  Adjust the HRRP and other outcomes measures for patient attributes associated with higher readmissions, including socioeconomic status, to avoid disincentivizing hospitals to care for high-risk individuals  Maintain transparency by reporting raw hospitalization and mortality rates among other patient-centered outcomes for underperforming hospitals to reveal disparities and encourage innovation and advancement in care and allow consumer awareness and choice HVBP ¼ hospital value-based purchasing; other abbreviations as in Tables 1, 2, and 4.

than other hospitals, a substantial portion of the

In this context, the 21st Century Cures Act legis-

elevated RSRRs is due to differences in the patient

lates CMS to stratify hospitals according to the pro-

populations beyond institutional control. Socioeco-

portion of admissions for patients dually enrolled

nomically disadvantaged individuals have fewer re-

with Medicare and Medicaid starting in fiscal year

sources, lower baseline health status, and greater

2019 (8,16). Performance will be assessed, and pen-

health care use rates (40–44).

alties assigned, within each of 5 strata defined by the

Within the Medicare population, dual enrollment

proportion of dually enrolled beneficiaries. It remains

in Medicare and Medicaid identifies individuals with

unclear how this revised system will change the

low income and marks socioeconomic disadvantage.

financial penalties long term, as it may incompletely

These patients are sicker, require greater health care

account for hospital differences and may paradoxi-

expenditures, and have significantly higher read-

cally serve to preserve inequalities in care (50,51).

mission rates than other patients after controlling for

However, the intervention does seem to substantially

medical comorbidities (40,45,46) (Table 6). These

reduce the financial burden and proportion of safety-

differences may be due to unmeasured confounders,

net hospitals penalized (40,52).

including functional limitations, diminished com-

Medically complex patients may also be treated

munity and caregiver support, cognitive impairment,

inequitably under the current HRRP adjustment al-

reduced health literacy, poor medical compliance,

gorithm. Because the HRRP relies on administrative

limited transportation resources, unstable housing,

claims, its risk adjustment algorithms may not be

or a multiplicative effect of the elevated concentra-

capable of appropriately accounting for hospital dif-

tion of multiple clinical risk factors (47,48). Caring for

ferences in sickness intensity or complexity; these

patients at high social risk is therefore disincentivized

factors may mischaracterize patients and admissions

by the HRRP, as it puts hospitals in greater danger of

(40). In general, risk prediction models for read-

penalty.

mission, including the HRRP calculation, poorly

Because of the complex relationship between

discriminate low- and high-risk patients (53,54).

quality of care, social and societal factors, and read-

Inadequate assessment of functional status, frailty,

missions, whether to account for patient socioeco-

and cognitive status, among other attributes that can

nomic risk in readmissions calculations is profoundly

drive potentially avoidable hospital readmissions,

controversial. Implementation of the HRRP has been

likely contributes to the limited accuracy and vari-

associated with both narrowing of racial disparities in

ability

readmission rates, suggesting a beneficial impact on

calculations (45,53,55). Alternative endpoints such

equity

without

socioeconomic

adjustment,

of

the

HRRP

and

other

risk-prediction

and

as all-cause readmission may be even more prob-

widening disparities in the safety net, suggesting

lematic given the inability to model even HF cause-

harm (17,38,49). Alternatively, ongoing bias and

specific admissions.

discrimination within health care remain sources of

Beyond inadequate risk adjustment, the mathe-

inequality that merit highlighting, and risk stan-

matics of the HRRP penalty perpetuates greater pen-

dardization may warrant further adjustment to pre-

alties on hospitals that may have been initially

vent penalizing hospitals for societal factors beyond

unfairly punished. Hospitals that received larger

their control.

penalties in previous years tend to garner ongoing

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greater penalties, despite substantial improvements

for mortality relative to readmission, could appro-

in outcomes, because of gains by the hospital com-

priately balance the importance of these outcomes

munity as a whole (37). Hospitals that started with

while incentivizing progress for both.

RSRRs further below the mean continue to play catch-

Both mortality and admissions could be incorpo-

up because every year one-half of hospitals have

rated in a weighted measure that also includes

RSRRs beneath the mean for each target condition.

patient-reported outcomes, observation stays, and

Consequently, the vast majority of hospitals are

emergency department visits. Combination of these

penalized under the HRRP each year, regardless of

events into a single criterion would challenge strate-

whether they improved their absolute readmissions

gies to “game” the HRRP metric and ensure that

rate (9) (Table 2).

focused methods to avoid readmissions also consider

CONSENSUS, DEBATE, AND RECOMMENDATIONS A few authors and some professional societies support eliminating the HRRP because they believe rehospitalization is not a reliable marker of appropriate timing and quality of hospital discharge, transition of care, and long-term quality, and that the current program has decreased patient survival (56) (Online Appendix B). However, most of the author groups concur that that iteration and improvement of the HRRP is necessary and appropriate (Table 7). Of many potential changes, we identified consensus advancements that could be implemented to better achieve the aims of the HRRP and improve patient health. Policy makers should consider these changes to improve program efficacy and reduce unintended consequences. Areas in which there is ongoing debate merit generation of new evidence, if possible, to allow logical emendation of the HRRP. In cases in which controversy cannot be resolved with available or producible data, we acknowledge that reasonable people can disagree until enough proof exists to support 1 interpretation over another. IMPROVE THE READMISSIONS MEASURE. The read-

missions measure should include all post-discharge care, including observation stays and emergency department visits, so that it more accurately reflects patients seeking emergent care after discharge. In addition, mortality should be accounted for as an indicator of superior process measures and long-term patient-centered benefit, to address the disproportionate relative severity of the rehospitalization penalty compared with the HVBP fine for increased 30-day mortality (22,57). One possible mechanism

the effect on mortality and patient well-being. Patient-reported outcome measurements should be incorporated with oversight from patients and patient representatives. If a composite was created, the components of the metric including mortality and rehospitalization rates should remain separately publicly reported to continue to allow consumer awareness and choice. Research is needed into the potential implications of alternative iterations of the HRRP. This research should include the use of a single all-cause readmissions and mortality metric, utilizing home time or days alive and out of the hospital such as with the excess days in acute care measures, transition to fixed versus

relative

performance

targets

recently

endorsed by MedPAC, or implementing different time frames potentially with a graduated penalty that is highest immediately after hospital discharge and wanes with increasing follow-up time (eliminating or curbing the arbitrary 30-day time frame) (16,58–60). It is unclear whether legislators will combine the HRRP and HVBP into a single comprehensive program to appropriately balance penalties. Finally, mortality after hospital admission for HF has continued to climb for the past decade, although it remains controversial whether implementation of the HRRP is causal or unrelated (16,35,36). This outcome may be due to increasingly ill patient admissions or improved reporting, but at the very least the HRRP seems to have been unable to stem this rising tide. The underlying causes of this trend should be uncovered and remedied while providing clinicians and health systems with practical guidance and implementation strategies to promote health and enhance patient-centeredness.

could adjust rates of readmissions for post-discharge

IMPROVE

mortality; however, similar metrics have not been

MEASURE. The HRRP should be adjusted for those

EQUITY

broadly tested. Another possible change would create

patient attributes known to be associated with

a composite measure, although hospital readmissions

higher readmissions, including socioeconomic sta-

numerically overwhelm mortality, and this would

tus, to avoid creating a disincentive for hospitals to

require broader programmatic change through legis-

care for high-risk individuals. Federal and indepen-

lation. Nevertheless, incorporation of the HRRP and

dent

HVBP into a single program, with greater weighting

effectively shrink the financial disparity between

simulations

UNDER

suggest

THE

this

READMISSIONS

approach

would

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Psotka et al.

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safety-net Although

Hospital Readmissions Reduction Program

and

non–safety-net

stratification

hospitals

(16,40).

run, improving risk adjustment by incorporating in-

groups under the HRRP started in 2019, this is un-

formation from additional sources and perhaps the

likely to comprehensively account for hospital and

electronic health record may better account for some

patient differences and may preserve inequalities in

disparities in future HRRP versions. More broadly,

care (50). Alternatively, simply adding socioeco-

treatment of underserved and marginalized societal

nomic status to the risk adjustment model may

groups, including those based on race and poverty,

similarly impair creation of a fair and just system by

will continue to complicate financial incentive struc-

hiding extant care disparities and not remedying

tures for quality and value-based care. The root cau-

their cause. To reduce this risk however socioeco-

ses of these inequalities need to be ascertained and

nomic

transparency

addressed before any health care system can be

should be maintained by reporting raw hospitaliza-

equitable and just and move thoughtfully into the

tion and mortality rates among other patient-

future.

is

socioeconomic

and equitably from outcome incentives. In the long

peer

information

into

addressed,

centered outcomes for underperforming hospitals to encourage innovation and advancement.

continue to be needed to establish growing consensus

FUTURE DIRECTIONS

and novel solutions. A lofty goal will be to focus on

Overall, the HRRP has galvanized attention on HF care but needs to be molded into a relevant, patientcentered, patient-sensitive, health-focused program for the future. The HRRP should facilitate change in addition

to

assessing

Advocacy, new research, and continued vigilant assessment of the HRRP and its future iterations

penalties.

Hospital-

and

community-based interventions that improve desired outcome metrics such as readmission need to be continually tested, publicized, and practiced. Robust qualitative and implementation research regarding

prevention

of

rehospitalization

with

expanding

methodology as well as avoiding incident hospitalization by preventing HF. Although our current mechanisms for hospital public reporting and valuebased payment do not allow for HRRP-type incentivization strategies to prevent initial admissions, accountable care organizations may use this opportunity to take the lead on improving health for patients with HF in the future.

structures and processes of care within pragmatic trials of real-world interventions are required to

ADDRESS FOR CORRESPONDENCE: Dr. Mitchell A.

determine best practices. Greater focus on the

Psotka, Inova Heart and Vascular Institute, 3300

execution of specific and validated strategies will be

Gallows Road, Falls Church, Virginia 22042. E-mail:

necessary to ensure that patients benefit sufficiently

[email protected]. Twitter: @mpsotka.

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KEY WORDS 30-day readmission, heart failure, HRRP, Medicare

61. Khera R, Pandey A, Ayers CR, et al. Contemporary epidemiology of heart failure

A PP END IX For supplemental appendices, please see the online version of this paper.

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