A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.
“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.
After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”
“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”
- The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
. .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
- If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
. .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
- “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
. . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
- Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
. .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
- HRRP may even have increased the death rates for patients with heart failure.
. .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”
“The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.