JAMA findings suggest 'unintended harm' from Hospital Readmissions Reduction Program

Meg Bryant

Dec. 21, 2018

Dive Brief:

• New evidence links CMS’ Hospital Readmissions Reduction Program to unintended harm in some patients, a JAMA editorial suggests. 
• Researchers analyzed 8.3 million hospitalizations of Medicare enrollees for heart failure, acute myocardial infarction and pneumonia over four periods from April 2005 through March 2015. Thirty-day post-discharge mortality for heart failure patients rose following announcement of HRRP and after implementation. 
• The findings raise concerns about whether the program is a reliable measure of hospital quality and basis for financial penalties, writes Gregg Fonarow of Ronald Reagan UCLA Medical Center. 

Dive Insight:

Part of the Affordable Care Act, HRRP seeks to curb healthcare costs and improve care by incentivizing hospitals to reduce 30-day risk-standardized readmissions for six conditions: heart failure, AMI, pneumonia, chronic obstructive pulmonary disease, hip/knee replacement and coronary artery bypass graft surgery. Hospitals with higher-than-expected readmission rates risk being docked up to 30% of their normal reimbursement. 

In fiscal 2018, eight in 10 hospitals subject to HRRP were penalized, resulting in $564 million less in payments, Fonarow notes.

In the new study, published Friday in JAMA, HRRP was associated with a 0.49% increase in 30-day post-discharge mortality in heart failure patients between 2007-2010 and 2010-2012, and a 0.52% jump from 2010-2012 to 2012-2015. No significant change was seen in heart attack patients, but there was also a significant increase in pneumonia patients following announcement and implementation of the program.

Previous studies have differed on whether HRRP puts vulnerable patients at risk. A 2017 study in JAMA Cardiology found that while the program reduced heart failure readmissions, mortality in those patients went up. However, a JAMA study published this fall found no link between the HRRP and increases in in-hospital or post-discharge mortality rates among Medicare beneficiaries.

Fonarow points to a separate analysis of clinical data from the American Heart Association's Get With the Guidelines – Heart Failure that found 30-day mortality rose under HRRP. The risk of harm was consistent across multiple subgroups and sensitivity analyses.

The findings provide “important new insights into the association of the HRRP with increases in mortality among patients hospitalized for heart failure, and raises additional concerns regarding potential unintended harms among patient with pneumonia,” Fonarow writes. “Irrespective of the intent of the policy, there is no evidence that patients have benefited from the HRRP.”

He urges lawmakers and CMS to consider alternative strategies to reduce avoidable readmissions and improve patient outcomes.

https://www.healthcaredive.com/news/jama-findings-suggest-unintended-harm-from-hospital-readmissions-reductio/544950/