Unintended Harm Associated With the Hospital Readmissions Reduction Program.

Health care expenditures continue to increase in the United States, and there have been considerable efforts over the past decade to use health policies, financial incentives, and alternative payment models to address this important issue. Starting in 2007, the Centers for Medicaid & Medicare Services (CMS) sought to reduce early readmissions for common medical conditions among Medicare beneficiaries. The CMS policy approaches included increasing transparency through public reporting of hospital 30-day risk standardized readmission rates (2007-2009 discharges) starting in 2009 and providing financial incentives tied to readmissions though the Hospital Readmissions Reduction Program (HRRP), passed under the Patient Protection and Affordable Care Act of 2010.1 The HRRP imposed financial penalties on hospitals based on rates of 30-day risk-standardized hospital readmission for heart failure, acute myocardial infarction, and pneumonia, with up to 3% of a hospital’s total Medicare revenue from admissions for any condition (target or nontarget) at risk. In fiscal year 2018, 80% of the hospitals subject to the HRRP have been penalized, amounting to $564 million in reduced payments by Medicare.2 The introduction of the HRRP was associated with reductions in hospital readmissions nationally, and the program has been declared a success and worthy of expansion by policy makers.3-5 But, the initial reports that evaluated the HRRP presented temporal changes in readmission rates without fully evaluating how those reductions were achieved or whether there were any unintended consequences. From the inception of the 30-day readmission measure for public reporting and the HRRP, significant concerns have been raised regarding whether the 30-day readmission rate is an accurate measure of hospital quality and a valid basis for financial penalties to be applied.6-9 Because the readmission model is risk adjusted based on administrative claims, concerns have been raised that it cannot adequately adjust for illness severity or medical complexity and is subject to variation in coding, which can result in hospitals being penalized based on the patients they care for rather than the quality of care provided.6 This policy has offered strong financial incentives for hospitals to reduce 30-day readmission rates for target conditions, but it has been implemented without any additional resources being provided to hospitals, without the provision of evidence-based guidance on how to safely and effectively achieve the stated readmission goals, and without any prospective testing.8,9 Although the large financial penalties were intended to incentivize hospitals to invest in improved transitions of care, these penalties may have instead encouraged restriction of necessary inpatient care within the first 30 days of hospital discharge through inappropriate triage strategies in emergency departments, increased use of observation stays when inpatient admissions would have been warranted, and delayed clinically indicated readmissions just beyond discharge day 30.8,9 It now appears that the reductions in readmissions for targeted conditions, including heart failure, acute myocardial infarction, and pneumonia, after the implementation of the HRRP were not the result of improved transitional care quality, which would have decreased unplanned returns to the hospital within the first 30 days. Instead, the apparent reductions were largely driven by unplanned returns to the hospital within 30 days of being directly discharged from the emergency department or coded as observation stays.5 Because the financial penalties have been applied disproportionately on teaching and safety net hospitals, the HRRP also may have hindered the ability of these hospitals to provide care for vulnerable and sicker populations, who are at the highest risk for poor outcomes.6,8 Further, the exclusive focus on reducing 30-day hospital readmissions may have diverted the attention and resources of hospitals from other quality improvement efforts and patient safety.8,9 Evidence has emerged suggesting the concerns regarding potential unintended consequences of the HRRP may be justified. While associated with reductions in 30-day inpatient readmissions for all 3 initially targeted conditions, the HRRP was also associated with an increase in unadjusted and riskadjusted postdischarge mortality in patients with heart failure, the patient population potentially most vulnerable to alterations in care.8-10 Using an interrupted time-series analysis approach, an analysis of clinical data from Get With The Guidelines Heart Failure linked to Medicare data demonstrated an increase in 30-day and 1-year mortality associated with the implementation of the HRRP.10 The findings of potential harm were consistent in multiple sensitivity analyses and in all subgroups studied. Evaluation of the full Medicare database also revealed a similar 1.3% absolute increase in 30-day risk-adjusted mortality in patients with heart failure after the implementation of the HRRP starting after 2010,4,9 whereas previous reports had indicated that from 1999 to 2010, 30-day unadjusted and risk-adjusted mortality rates had been declining.9 Additional studies have reported an increase in risk-adjusted mortality when analyzed 30 days from hospital admission or 30 days from discharge.8,11 Related article page 2542 Opinion