Data Hint at Unintended Consequences of Hospital Readmissions Reduction Program

The Hospital Readmissions Reduction Program (HRRP), enacted by the 2010 Affordable Care Act, appears to have led to an increase in deaths within 30 days of discharge in Medicare beneficiaries hospitalized for heart failure or pneumonia, leading researchers to conclude that more investigation is needed into the possibility that the program has had unintended negative consequences.

However, there was no such pattern seen in patients who had been hospitalized for acute MI.

“Though postdischarge deaths for patients with heart failure were increasing in the years prior to the HRRP, this trend accelerated after the program was established,” said Rishi K. Wadhera, MD (Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Boston, MA), first author of the new report. “In addition, death rates following a pneumonia hospitalization were stable before the HRRP, but increased after the program began.”

The study, published online today in JAMA, shows that the increase in deaths among heart failure and pneumonia patients was concentrated in those who had not been readmitted to the hospital. “This raises the possibility that the HRRP may have pushed some clinicians and hospitals to increasingly treat patients in emergency rooms and observation units, when they would have benefited from inpatient care, to avoid readmissions,” Wadhera added.

In an accompanying editorial, Gregg C. Fonarow, MD (Ronald Reagan UCLA Medical Center, Los Angeles, CA), says the new study together with other recent analyses provides “independently corroborated evidence that the HRRP was associated with increased postdischarge mortality among patients with heart failure, and new evidence that the HRRP was associated with increased mortality among patients hospitalized for pneumonia.”

Fonarow urges that, in light of the findings, “it is incumbent upon Congress and [the US Centers for Medicare & Medicaid Services (CMS)] to initiate an expeditious reconsideration and revision of this policy.”

In an email response, senior study author Robert W. Yeh, MD (Beth Israel Deaconess Medical Center), said caution should be exercised before undertaking further expansion of the penalties to more health conditions.

“But unfortunately, causality is really very difficult to establish with this type of analysis,” he added. “So, I want to be equally cautious in not overstating the strength of our evidence that the HRRP has definitively harmed patients. The HRRP has clearly been successful at reducing readmission, something which patients care about. Right now, I think we still don’t have a complete answer, and more work still needs to be done. “

Findings Concerning

CMS implemented the HRRP in 2012 to provide financial incentives for hospitals to reduce readmission rates. Wadhera and colleagues studied approximately 8 million Medicare patients hospitalized between April 2005 and March 2015, breaking the results down into four periods: two before the HRRP announcement, one immediately after the announcement, and one during the time when the program was implemented and hospitals were subjected to financial penalties.

For heart failure, there was 0.49% increase from baseline between the 2007-2010 and 2010-2012 time periods (P = 0.01) and a 0.52% increase between 2010-2012 and 2012-2015 (P = 0.001). For pneumonia, the corresponding increases were 0.26% (P = 0.01) and 0.44% (P < .001), respectively.

We believe our findings are very concerning, and that [CMS] should not expand the HRRP to all hospitalized conditions, as some policymakers have advocated for, so that we can better understand the factors driving these trends. Rishi Wadhera

Even after accounting for differences in severity of illness over time, the increase in 30-day postdischarge deaths after the HRRP was announced and implemented remained for patients hospitalized for heart failure or pneumonia.

The study also included patients hospitalized for acute MI. The HRRP announcement was associated with a decline in postdischarge mortality in this group that—unlike in patients with heart failure or pneumonia—did not significantly change after the policy was implemented. Analyses of mortality in the first 45 days from admission showed no significant association with increased deaths relative to pre-HRRP trends for any of the three conditions.

“We believe our findings are very concerning, and that [CMS] should not expand the HRRP to all hospitalized conditions, as some policymakers have advocated for, so that we can better understand the factors driving these trends,” Wadhera said.

The Medicare Payment Advisory Commission (MedPAC) maintains that the HRRP has succeeded across all conditions, including heart failure, acute MI, and pneumonia. In a June 2018 report to Congress, the group wrote that there was “no evidence to suggest that the readmission policy has increased mortality.”

To TCTMD, Yeh reiterated that the policy has led to decreases in readmission rates and to that end has been a success.

“Our results diverge from the findings of the MedPAC report but are consistent with more recent analyses from other independent groups,” he added. “Because the methods employed in the MedPAC report are not clear to us at this time, I can’t really comment on why our results might differ.”

For Fonarow, the evidence is clear that regardless of the intent of the policy, there is no evidence that the HRRP benefits patients.

“Alternative strategies can be deployed to more effectively achieve the goal of reducing avoidable readmissions, improve patient-prioritized outcomes like health status, while better protecting patients from unintentional harms, including preventable deaths,” he concludes.