Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program

Assessing the quality of public services: For-profits, chains, and concentration in the hospital market

We examine variation in US hospital quality across ownership, chain membership, and market concentration. We propose a new measure of quality derived from penalties imposed on hospitals under the flagship Hospital Readmissions Reduction Program, and use regression models to risk-adjust for hospital characteristics and county demographics. While the overall association between for-profit ownership and quality is negative, there is evidence of substantial heterogeneity. The quality of for-profit relative to non-profit hospitals declines with increasing market concentration. Moreover, the quality gap is primarily driven by for-profit chains. While the competition result mirrors earlier findings in the literature, the chain result appears to be new: it suggests that any potential quality gains afforded by chains are mostly realized by not-for-profit hospitals.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE

To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare were used.

STUDY DESIGN

Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

CONCLUSIONS

HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Association of hospital and market characteristics with 30-day readmission rates from 2009 to 2015

Objectives

The US government implemented the Hospital Readmission Reduction Program on 1 October 2012 to reduce readmission rates through financial penalties to hospitals with excessive readmissions. We conducted a pooled cross-sectional analysis of US hospitals from 2009 to 2015 to determine the association of the Hospital Readmission Reduction Program with 30-day readmissions.

Methods

We utilized multivariable linear regression with year and state fixed effects. The model was adjusted for hospital and market characteristics lagged by 1 year. Interaction effects of hospital and market characteristics with the Hospital Readmission Reduction Program indicator variable was also included to assess whether associations of Hospital Readmission Reduction Program with 30-day readmissions differed by these characteristics.

Results

In multivariable adjusted analysis, the main effect of the Hospital Readmission Reduction Program was a 3.80 percentage point (p < 0.001) decrease in readmission rates in 2013-2015 relative to 2009-2012. Hospitals with lower readmission rates overall included not-for-profit and government hospitals, medium and large hospitals, those in markets with a larger percentage of Hispanic residents, and population 65 years and older. Higher hospital readmission rates were observed among those with higher licensed practical nurse staffing ratio, larger Medicare and Medicaid share, and less competition. Statistically significant interaction effects between hospital/market characteristics and the Hospital Readmission Reduction Program on the outcome of 30-day readmission rates were present. Teaching hospitals, rural hospitals, and hospitals in markets with a higher percentage of residents who were Black experienced larger decreases in readmission rates. Hospitals with larger registered nurse staffing ratios and in markets with higher uninsured rate and percentage of residents with a high school education or greater experienced smaller decreases in readmission rates.

Conclusion

Findings of the current study support the effectiveness of the Hospital Readmission Reduction Program but also point to the need to consider the ability of hospitals to respond to penalties and incentives based on their characteristics during policy development.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

The effect of performance pay incentives on market frictions: evidence from medicare

Medicare has increased the use of performance pay incentives for hospitals, with the goal of increasing care coordination across providers, reducing market frictions, and ultimately to improve quality of care. This paper provides new empirical evidence by using novel operations and claims data from a large, independent home health care firm with the Hospital Readmissions Reduction Program (HRRP) penalty on hospitals providing identifying variation. We find that the penalty incentive to reduce re-hospitalizations passed through from hospitals to the firm for at least some types of patients, since it provided more care inputs for heart disease patients discharged from hospitals at greater penalty risk and that contributed more patients to the firm. This evidence suggests that HRRP helped increase coordination between hospitals and home health firms without formal integration. Greater home health effort does not appear to have led to lower patient readmissions.

Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives

Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.

Did the Hospital Readmissions Reduction Program Reduce Readmissions? An Assessment of Prior Evidence and New Estimates

In this article, we provide a comprehensive, empirical assessment of the hypothesis that the Hospital Readmissions Reduction Program (HRRP) affected hospital readmissions. In doing so, we provide evidence as to the validity of prior empirical approaches used to evaluate the HRRP and we present results from a previously unused approach to study this research question-a regression-kink design. Results of our analysis document that the empirical approaches used in most prior research assessing the efficacy of the HRRP often lack internal validity. Therefore, results from these studies may not be informative about the causal consequences of the HRRP. Results from our regression-kink analysis, which we validate, suggest that the HRRP had little effect on hospital readmissions. This finding contrasts with the results of most prior studies, which report that the HRRP significantly reduced readmissions. Our finding is consistent with conceptual considerations related to the assumptions underlying HRRP penalty: in particular, the difficulty of identifying preventable readmissions, the highly imperfect risk adjustment that affects the penalty determination, and the absence of proven tools to reduce readmissions.

Performance Pay in Hospitals: An Experiment on Bonus-Malus Incentives

Recent policy reforms in Germany require the introduction of a performance pay component with bonus–malus incentives in the inpatient care sector. We conduct a controlled online experiment with real hospital physicians from public hospitals and medical students in Germany, in which we investigate the effects of introducing a performance pay component with bonus–malus incentives to a simplified version of the German Diagnosis Related Groups (DRG) system using a sequential design with stylized routine cases. In both parts, participants choose between the patient optimal and profit maximizing treatment option for the same eight stylized routine cases. We find that the introduction of bonus–malus incentives only statistically significantly increases hospital physicians’ proportion of patient optimal choices for cases with high monetary baseline DRG incentives to choose the profit maximizing option. Medical students behave qualitatively similar. However, they are statistically significantly less patient oriented than real hospital physicians, and statistically significantly increase their patient optimal decisions with the introduction of bonus–malus incentives in all stylized routine cases. Overall, our results indicate that whether the introduction of a performance pay component with bonus–malus incentives to the (German) DRG system has a positive effect on the quality of care or not particularly depends on the monetary incentives implemented in the DRG system as well as the type of participants and their initial level of patient orientation.

Suitability of elderly adult hospital readmission rates for profiling readmissions in younger adult and pediatric populations

OBJECTIVE

To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children.

DATA SOURCES/STUDY SETTING

US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database.

STUDY DESIGN

Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients.

PRINCIPAL FINDINGS

Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R² .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R² .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R² .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic.

CONCLUSIONS

Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.

Impact of the Medicare hospital readmissions reduction program on vulnerable populations

BACKGROUND

The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score.

METHODS

Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics.

RESULTS

There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients.

CONCLUSIONS

The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.

The Supply of Hospital Care to Minority and Low-Income Communities and the Hospital Readmission Reduction Program

To determine if the Centers for Medicare and Medicaid Services Hospital Readmission Reduction Program reduced hospital discharges for penalized conditions in minority and low-income communities, we used hospital discharge data for 2006 and 2013 from Arizona, California, Colorado, Florida, New Jersey, New York, North Carolina, and Wisconsin and readmission data from the Medicare Hospital Compare website. Negative binomial regression was used for 6,564 zip codes for each year to estimate the association between the expected penalty for an excess readmission in the hospital service area and the number of hospital discharges for penalized conditions (acute myocardial infarction, congestive heart failure, and pneumonia) for zip codes. The results showed that the expected penalty for excess readmissions had a negative association with the number of discharges for acute myocardial infarction, congestive heart failure, and pneumonia. The negative association increased with the percentage of minority residents but not with the poverty rate.

Pay for performance for hospitals

BACKGROUND

Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care.

OBJECTIVES

Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic.

SELECTION CRITERIA

We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables.

MAIN RESULTS

We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance.

AUTHORS' CONCLUSIONS

It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.

The Effect Of The Hospital Readmissions Reduction Program On Readmission And Observation Stay Rates For Heart Failure

The Hospital Readmissions Reduction Program reduces Medicare prospective payments for hospitals with excess readmissions for selected diagnoses. By comparing data for patients who were readmitted or placed on observation status immediately before and immediately after the thirty-day cutoff for penalties, we sought to determine whether hospitals have responded to the program by shifting readmissions for heart failure to observation status. We used regression discontinuity, taking advantage of the cutoff to generate unbiased estimates of treatment effects. Overall, we found no evidence that the program has affected the use of observation stays. However, for nonpenalized hospitals, the use of observation status was 5.4 percent higher for patients returning to the hospital immediately before the thirty-day cutoff than for patients returning immediately after the cutoff, which suggests that some hospitals may have used observation status to help avoid penalties. Because differences in the cost-sharing rules may lead to higher out-of-pocket expenses for Medicare patients placed on observation status, the program could have an inequitable financial impact.

How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions?: an Analysis from 2007 to 2014 in Five US States

BACKGROUND

Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen.

OBJECTIVE

To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals.

DESIGN

Repeated cross-sectional analysis, stratified by safety-net status.

SUBJECTS

1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR.

MAIN MEASURES

Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014.

KEY RESULTS

Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P < 0.05). These trends continued following the passage of HRRP.

CONCLUSIONS

Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial

BACKGROUND

Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings.

OBJECTIVE

To evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission.

DESIGN

A non-blinded, pragmatic randomized controlled trial ( Clinicaltrials.gov : NCT02763202) conducted at two hospitals in Charlotte, North Carolina.

PATIENTS

A total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions.

INTERVENTION

Random allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941).

MAIN MEASURE

Thirty-day, unplanned, inpatient, or observation readmission rate.

KEY RESULTS

The 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02).

CONCLUSIONS

An intervention inclusive of contemporary recommendations does not reduce a high-risk population's 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions.

TRIAL REGISTRY

ClinicalTrials.gov ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202.

Racial and Ethnic Composition of Hospitals' Service Areas and the Likelihood of Being Penalized for Excess Readmissions by the Medicare Program

BACKGROUND

The Hospital Readmission Reduction Program (HRRP) disproportionately penalizes hospitals serving minority communities. The National Academy of Science, Engineering, and Medicine has recommended that the Centers for Medicare and Medicaid Services (CMS) consider adjusting for social risk factors in their risk adjustment methodology. This study examines the association between the racial and ethnic composition of a hospital market and the impact of other social risk factors on the probability of a hospital being penalized under the HRRP.

RESEARCH METHODS AND DATA

This study analyzes data from CMS, the American Hospital Association, and the American Community Survey for 3168 hospitals from 2013 to 2017. We used logistic regression models to estimate the association between the penalty status under HRRP and the racial and ethnic composition of a hospital market, and explored whether this association was moderated by other social risk factors.

RESULTS

Our results indicate that the probability of being penalized increases with the percentage of black and Asian residents in the hospital service area (HSA) and decreased with the percentage of Hispanic residents in the HSA. This association was reduced and became statistically insignificant when we controlled for other social risk factors. The strongest predictors of penalty status were the hospital's share of Medicaid patients and the percent of persons without a high school diploma in the HSA.

CONCLUSIONS

By incorporating relevant social risk factors in the reimbursement methodology, CMS could mitigate the negative effects of HRRP on hospitals serving minority communities.

Does a Reduction in Readmissions Result in Net Savings for Most Hospitals? An Examination of Medicare's Hospital Readmissions Reduction Program

This study aimed (1) to estimate the impact of an incremental reduction in excess readmissions on a hospital's Medicare reimbursement revenue, for hospitals subject to penalties under the Medicare's Hospital Readmissions Reduction Program and (2) to evaluate the economic case for an investment in a readmission reduction program. For 2,465 hospitals with excess readmissions in the Fiscal Year 2016 Hospital Compare data set, we (1) used the Hospital Readmissions Reduction Program statute to estimate hospital-specific Medicare reimbursement gains per an avoided readmission and (2) carried out a pro forma analysis of investment in a broad-scale readmission reduction program under conservative assumptions regarding program effectiveness and using program costs from earlier studies. For an average hospital, avoiding one excess readmission would result in reimbursement gains of $10,000 to $58,000 for Medicare discharges. The economic case for investments in a readmission reduction effort was strong overall, with the possible exception of hospitals with low excess readmissions.

The Affordable Care Act and Its Effects on Physician Leadership: A Qualitative Systematic Review

OBJECTIVES

The Affordable Care Act (ACA) shifted the focus in medical care from quantity to quality. This qualitative systematic review aimed to determine the key skills necessary for effective physician leaders after the implementation of the ACA, and to compare them with key skills identified prior to its implementation.

METHODS

A qualitative systematic review was conducted. A systematic literature search on leadership skills for physicians returned 26 articles published between 2009 and 2016. Thematic analysis was used to categorize the data presented in each article. The results from the thematic analysis were then compared with a similar article published before the implementation of the ACA.

RESULTS

Teamwork and team-building, communication, and self-awareness skills were mentioned most often. The percentage of articles mentioning teamwork and team-building skills (61.5%) was significantly greater than the percentage (25%) reported before the implementation of the ACA (P ≤ .04).

CONCLUSION

With the shift toward quality of patient care, health care workers at all levels should strive to work as a team to provide the best quality of care at all stages of patient care.

Effects of Postacute Multidisciplinary Rehabilitation Including Exercise in Out-of-Hospital Settings in the Aged: Systematic Review and Meta-analysis

OBJECTIVE

Many older individuals receive rehabilitation in an out-of-hospital setting (OOHS) after acute hospitalization; however, its effect on mobility and unplanned hospital readmission is unclear. Therefore, a systematic review and meta-analysis were conducted on this topic.

DATA SOURCES

Medline OVID, Embase OVID, and CINAHL were searched from their inception until February 22, 2018.

STUDY SELECTION

OOHS (ie, skilled nursing facilities, outpatient clinics, or community-based at home) randomized trials studying the effect of multidisciplinary rehabilitation were selected, including those assessing exercise in older patients (mean age ≥65y) after discharge from hospital after an acute illness.

DATA EXTRACTION

Two reviewers independently selected the studies, performed independent data extraction, and assessed the risk of bias. Outcomes were pooled using fixed- or random-effect models as appropriate. The main outcomes were mobility at and unplanned hospital readmission within 3 months of discharge.

DATA SYNTHESIS

A total of 15 studies (1255 patients) were included in the systematic review and 12 were included in the meta-analysis (7 assessing mobility using the 6-minute walk distance [6MWD] test and 7 assessing unplanned hospital readmission). Based on the 6MWD, patients receiving rehabilitation walked an average of 23 m more than controls (95% confidence interval [CI]=: -1.34 to 48.32; I²: 51%). Rehabilitation did not lower the 3-month risk of unplanned hospital readmission (risk ratio: 0.93; 95% CI: 0.73-1.19; I²: 34%). The risk of bias was present, mainly due to the nonblinded outcome assessment in 3 studies, and 7 studies scored this unclearly.

CONCLUSION

OOHS-based multidisciplinary rehabilitation leads to improved mobility in older patients 3 months after they are discharged from hospital following an acute illness and is not associated with a lower risk of unplanned hospital readmission within 3 months of discharge. However, the wide 95% CIs indicate that the evidence is not robust.

Applicability of Publicly Reported Hospital Readmission Measures to Unreported Conditions and Other Patient Populations: A Cross-sectional All-Payer Study

BACKGROUND

Readmission rates after hospitalizations for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among Medicare beneficiaries are used to assess quality and determine reimbursement. Whether these measures reflect readmission rates for other conditions or insurance groups is unknown.

OBJECTIVE

To investigate whether hospital-level 30-day readmission measures for publicly reported conditions (HF, AMI, and pneumonia) among Medicare patients reflect those for Medicare patients hospitalized for unreported conditions or non-Medicare patients hospitalized with HF, AMI, or pneumonia.

DESIGN

Cross-sectional.

SETTING

Population-based.

PARTICIPANTS

Hospitals in the all-payer Nationwide Readmissions Database in 2013 and 2014.

MEASUREMENTS

Hospital-level 30-day all-cause risk-standardized excess readmission ratios (ERRs) were compared for 3 groups of patients: Medicare beneficiaries admitted for HF, AMI, or pneumonia (Medicare reported group); Medicare beneficiaries admitted for other conditions (Medicare unreported group); and non-Medicare beneficiaries admitted for HF, AMI, or pneumonia (non-Medicare group).

RESULTS

Within-hospital differences in ERRs varied widely among groups. Medicare reported ratios differed from Medicare unreported ratios by more than 0.1 for 29% of hospitals and from non-Medicare ratios by more than 0.1 for 46% of hospitals. Among hospitals with higher readmission ratios, ERRs for the Medicare reported group tended to overestimate ERRs for the non-Medicare group but underestimate those for the Medicare unreported group.

LIMITATION

Medicare groups and risk adjustment differed slightly from those used by the Centers for Medicare & Medicaid Services.

CONCLUSION

Hospital ERRs, as estimated by Medicare to determine financial penalties, have poor agreement with corresponding measures for populations and conditions not tied to financial penalties. Current publicly reported measures may not be good surrogates for overall hospital quality related to 30-day readmissions.

PRIMARY FUNDING SOURCE

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

Readmission Patterns After GI Cancer Hospitalizations: The Medical Versus Surgical Patient

PURPOSE

Readmission within 30 days has been used as a metric for quality of care received at hospitals for certain diagnoses. In the era of accountability, value-based care, and increasing cancer costs, policymakers are looking into cancer readmissions as well. It is important to describe the readmission profile of patients with cancer in the most clinically relevant approach to inform policy and health care delivery that can positively impact patient outcomes.

PATIENTS AND METHODS

We conducted a retrospective cohort study using linked Texas Cancer Registry and Medicare claims data. We included elderly Texas residents diagnosed with GI cancer and identified risk factors for unplanned readmission using generalized estimating equations, comparing medical with surgical cancer-related hospitalizations.

RESULTS

We analyzed 69,693 hospitalizations from 31,736 patients. The unplanned readmission rate was higher after medical hospitalizations than after surgical hospitalizations (21.6% v 13.4%, respectively). Shared risk factors for readmission after medical and surgical hospitalizations included advanced disease stage, high comorbidity index, and emergency room visit and radiation therapy within 30 days before index hospitalization. Several other associated factors and reasons for readmission were noted to be unique to medical or surgical hospitalizations alone.

CONCLUSION

Unplanned readmissions among elderly patients with GI cancer are more common after medical hospitalizations compared with surgical hospitalizations. There are shared risk factors and unique risk factors for these hospitalizations that can inform policy, health care delivery, and interventions to reduce readmissions. Other findings underscore the importance of care coordination and comorbidity management in this patient population.

The Effect of the Hospital Readmission Reduction Program on the Duration of Observation Stays: Using Regression Discontinuity to Estimate Causal Effects

Research Objective:

Determine whether hospitals are increasing the duration of observation stays following index admission for heart failure to avoid potential payment penalties from the Hospital Readmission Reduction Program.

Study Design:

The Hospital Readmission Reduction Program applies a 30-day cutoff after which readmissions are no longer penalized. Given this seemingly arbitrary cutoff, we use regression discontinuity design, a quasi-experimental research design that can be used to make causal inferences.

Population Studied:

The High Value Healthcare Collaborative includes member healthcare systems covering 57% of the nation’s hospital referral regions. We used Medicare claims data including all patients residing within these regions. The study included patients with index admissions for heart failure from January 1, 2012 to June 30, 2015 and a subsequent observation stay within 60 days. We excluded hospitals with fewer than 25 heart failure readmissions in a year or fewer than 5 observation stays in a year and patients with subsequent observation stays at a different hospital.

Principal Findings:

Overall, there was no discontinuity at the 30-day cutoff in the duration of observation stays, the percent of observation stays over 12 hours, or the percent of observation stays over 24 hours. In the sub-analysis, the discontinuity was significant for non-penalized.

Conclusion:

The findings reveal evidence that the HRRP has resulted in an increase in the duration of observation stays for some non-penalized hospitals.

Hospital Readmissions Reduction Program: Intended and Unintended Effects

This study examines whether the Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with excess readmissions for certain conditions, has reduced hospital readmissions and led to unintended consequences. Our analyses of Florida hospital administrative data between 2008 and 2014 find that the HRRP resulted in a reduction in the likelihood of readmissions by 1% to 2% for traditional Medicare (TM) beneficiaries with heart failure, pneumonia, or chronic obstructive pulmonary disease. Readmission rates for Medicare Advantage (MA) beneficiaries and privately insured patients with heart attack and heart failure decreased even more than TM patients with the same target condition (e.g., for heart attack, the likelihood for TM beneficiaries to be remitted is 2.2% higher than MA beneficiaries and 2.3% higher than privately insured patients). We do not find any evidence of cost-shifting, delayed readmission, or selection on discharge disposition or patient income. However, the HRRP reduced the likelihood of Hispanic patients with target conditions being admitted by 2% to 4%.

External validation of the breast reconstruction risk assessment calculator

INTRODUCTION

The Breast reconstruction Risk Assessment (BRA) Score estimates patient-specific risk for postsurgical complications using an individual's unique combination of preoperative variables. In this report, we externally validate the BRA Score models for surgical site infection, seroma, and explantation in a large sample of intra-institutional patients who underwent prosthetic breast reconstruction.

METHODS

We reviewed all initiated tissue expander/implant reconstructions by the senior authors from January 2004 to December 2015. BRA Score risk estimates were computed for each patient and compared against observed rates of complications. Hosmer-Lemeshow goodness-of-fit test, concordance statistic, and Brier score were used to assess the calibration, discrimination, and accuracy of the models, respectively.

RESULTS

Of the 1152 patients (1743 breasts) reviewed, 855 patients (1333 breasts) had complete data for BRA-score calculations and were included for analysis. Hosmer-Lemeshow tests for calibration demonstrated a good agreement between observed and predicted outcomes for surgical site infection (SSI) and seroma models (P-values of 0.33 and 0.16, respectively). In contrast, predicted rates of explantation deviated from observed rates (Hosmer-Lemeshow P-value of 0.04). C statistics demonstrated good discrimination for SSI, seroma, and explantation (0.73, 0.69, and 0.78, respectively).

CONCLUSIONS

In this external validation study, the BRA Score tissue expander/implant reconstruction models performed with generally good calibration, discrimination, and accuracy. Some weaknesses in certain models were identified as targets for future improvement. Taken together, these analyses validate the clinical utility of the BRA score risk models in predicting 30-day outcomes.