U.S. Federal Readmission Fines Linked to Higher Mortality

A new study suggests that the U.S. Hospital Readmission Reduction Program (HRRP) may be so focused on avoiding readmissions that heart failure (HF) related death rates are increasing.

Researchers at Harvard Medical School (HMS; Boston, MA, USA), the University of California, Los Angeles (UCLA; USA), and other institutions conducted a study to examine the association of the HRRP with readmission and mortality outcomes among 115,245 Medicare patients hospitalized with HF between January 2006 and December 2014 in 416 U.S. hospitals. Time intervals related to HRRP were examined before implementation (March 31, 2010), during HRRP implementation, and after penalties went into effect (October 1, 2012). Main outcomes and measures were 30-day and one year all-cause readmission and mortality rates.

The results showed that 30-day risk-adjusted readmission rate declined from 20% before HRRP implementation to 18.4% in the HRRP penalties phase. In contrast, 30-day risk-adjusted mortality rate increased from 7.2% before HRRP implementation to 8.6% in the HRRP penalties phase. One year risk-adjusted readmission and mortality rates followed a similar pattern; risk-adjusted readmission rate declined from 57.2% to 56.3%, and risk-adjusted mortality rate increased from 31.3% to 36.3% after HRRP implementation. The study was published on November 12, 2017, in JAMA Cardiology.

“To avoid the penalties, hospitals now have incentives to keep patients out of hospitals longer, possibly even if previously some of these patients would have been readmitted earlier for clinical reasons,” said lead author Ankur Gupta, PhD, a cardiovascular researcher at Harvard Medical School. “Therefore, this policy of reducing readmissions is aimed at reducing utilization for hospitals, rather than having a direct focus on improving quality of patient care and outcomes.”

“Medicare financially penalizes approximately two-thirds of U.S. hospitals, based on their 30-day readmission rates,” said senior author Professor Gregg Fonarow, MD, co-chief of cardiology at UCLA. “This data suggests it also incentivized strategies that unintentionally harmed patients with heart failure. The policy should focus on incentivizing improving quality and patient-centered outcomes of those with heart failure, and not on a misguided utilization metric of re-hospitalizations.”

The HRRP was introduced by Medicare (Baltimore, MD, USA) in order to improve patient care by penalizing hospitals with poor outcomes. One key outcome measure is the readmission rate; one possible result is that Medicare may begin to withhold reimbursements to hospitals with excessively high readmission rates.

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Harvard Medical School
University of California, Los Angeles