A Call To Recognize The Danger of the Hospital Readmissions Reduction Program

By Megan Headley

The Hospital Readmissions Reduction Program (HRRP) was enacted in 2012 to make headway in reducing the estimated $17 billion in Medicare spent annually on avoidable hospital readmissions, but critics note that the penalty-based program may not be the best solution for improving quality of care. Now a November 2017 study published in JAMA Cardiology exploring the association of the HRRP with trends in readmission and mortality rates among fee-for-service Medicare beneficiaries hospitalized with heart failure points to a disconcerting correlation.

The observational study of 115,245 fee-for-service Medicare beneficiaries hospitalized with heart failure at 416 sites across the United States concluded that implementation of the HRRP was associated with a subsequent decrease in 30-day and 1-year risk-adjusted readmissions, as well as an increase in 30-day and 1-year risk-adjusted mortality.

The study’s authors note that the findings point to a reversal in a decades-long trend of declining death rates among patients with heart failure. It’s a trend that may indicate that the readmissions program is pushing hospitals to inadvertently put costs before patients’ best interest.

As senior author Dr. Gregg Fonarow, the Eliot Corday Professor of Cardiovascular Medicine and Science at the David Geffen School of Medicine at UCLA and co-chief of cardiology, points out in a news release on the study, “If a patient dies, then that patient cannot be readmitted.”

According to Dr. Gerald Maccioli, Envision Healthcare Chief Quality Officer, it’s not a big surprise that mortality rates have risen along with HRRP implementation.

“The goal of reducing the readmission rates for heart failure makes sense—we want to keep people out of hospitals—but it wasn’t incentivized well,” he says. “The program set up an artificial incentive that measured utilization rather than quality.”

Finding the Right Comparisons

Maccioli, like many other providers, recognize the need to make the shift to care that is based on value, not volume.

“We’ve got to get healthcare costs under control in this country. Nobody’s debating that. I think the question is the mechanism that was used,” Maccioli says. Echoing the study’s authors, Maccioli points to the recent JAMA Cardiology study as evidence of the flaws in the program established by the Centers for Medicare & Medicaid Services.

The heart failure program financially penalizes hospitals for any readmissions within 30 days. But for Maccioli, penalizing a hospital based on readmission rates without looking deeper into the triggers for readmission is akin to comparing apples and oranges. “What happens is we’re really taking a utilization measure and saying that it’s a quality of care measure. It’s in no way, shape or form the same thing,” he says.

The unintended consequences of the readmissions reduction program revealed in the JAMA Cardiology study demonstrates that the cost improvements may not be worth the consequences on quality.

“In my mind, this study is very valuable for what it shows. It shows that we’ve got to get away from this false drumbeat of saying utilization and quality are the same thing when in fact they’re not,” Maccioli says.

Exploring the Triggers

Maccioli sees the incentive for the facility (in this case, the hospital readmissions penalty) as being diametrically opposed to the best interest of the patient. The patient’s best interest isn’t readmission, per se—it’s readmission when one’s worsened condition calls for readmission.

“In this study your 30-day readmissions went down but mortality went up. Well that’s putting dollars over lives,” Maccioli says.

Maccioli speculates that hospitals may be raising the thresholds for readmission based on this perversity of incentive, leading to the dour data revealed by this study. “If you admit a patient who needs it, the facility is going to lose money. You’re not really incentivized to do what’s best for the patient, your incentive is to do what’s best for the facility.”

But Maccioli adds that his real concern is that when one looks at the program as it’s outlined over the next few years, the monetary penalties for hospitals for readmission are going to become even more substantial. “I think that is one of the great dangers to patient safety going on right now in this country. In my opinion, all these readmission programs need to stop immediately until we get a much better handle on a way to measure proper quality and utilization,” he says.

While this study didn’t break down the thresholds and triggers for readmission, Maccioli sees that as the next step for exploring a solution that encourages cost-effective care balanced with quality.

“It’s the right question—how do the triggers change? How do the processes change in terms of readmitting?

He sees the next step as a longitudinal study tracking patients at the episodes of care, then tracking mortality and total cost at a 6- and 12-month period. “If patients who were admitted twice have a lower mortality over the course of the year, then let’s look at the cost of care of those episodes. Let’s not say we’re not going to readmit people,” Maccioli suggests.

Of course, finding a readmission reduction solution that works is the big challenge facing CMS and hospitals around the nation. For his part, Maccioli offers an alternative. “I think incentives should be annualized and tied to a two-fold matrix: First, what is the observed/expected mortality for a certain condition and, second, what is the cost?”

The researchers are now studying which types of hospitals and patients are most affected by the trend revealed by their data.

Making the Patient the Focus Again

Today’s healthcare environments are focused on being “patient-centric” but the JAMA Cardiology study points out that this may be a claim that’s only façade deep.

“Let’s say at the six months we discern that in this case heart patients need two admissions. If they’re a classic heart failure patient, then let’s ask how we control those costs. We identify first what is the care needed for the best outcome for the patient and then once we know that, then let’s look at the cost of the episodes that are needed,” Maccioli proposes. “Let’s not say we’re going to look at the episodes and we’ll see if patients survive or not. The focal point of this program needs to shift and be much more patient—or consumer—centric.”

Megan Headley is a contributing writer to Patient Safety & Quality Healthcare.