Some researchers say hospitals are punished for post-discharge factors out of their control.

Oct. 13—New research challenges the fairness and accuracy of the government’s quality measures and penalties for exceeding hospital readmissions standards and suggest changes are warranted.

The Hospital Readmissions Reductions Program (HRRP), which is a quality improvement component of the Affordable Care Act (ACA), cuts hospitals’ base inpatient Medicare claims by up to 3 percent if they exceed 30-day readmission rates in several categories. Medicare 30-day readmission rates have fallen 8 percent over the last six years, but HRRP penalties have continued to increase, according to federal data.

One recent Health Affairsstudy  examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients over 65 in four states for three conditions. The researchers found that “the hospital level quality signal captured in readmission risk was highest on the first day after discharge and declined rapidly until it reached a nadir at seven days…” 

They wrote that the HRRP was built on the premise that hospitals’ scope of responsibility should include post-discharge care coordination, “although essentially no empirical evidence supports the use of a 30-day readmission interval for assessing hospital-modifiable quality in all settings and clinical domains … It is not clear whether hospitals can practicably affect care for such a long period after discharge. For this reason, many researchers remain skeptical about the use of a 30-day readmission interval for all conditions.”

The study said the Centers for Medicare and Medicaid Services focused “on motivating individual facilities to reduce their readmission rates, while little attention has been paid to the role of health care providers outside the hospital setting.” They noted that “the relative proportions of risk attributable to hospitals, post-acute care, or non-health care factors, are unknown.”

The authors recommended further research into assessing the post-discharge risk posed by other healthcare providers. 

The study sample included 15 million hospitalizations of 6.7 million unique patients at 910 hospitals.

Confirms Belief

Karen Joynt, MD, a cardiologist and health policy researcher with the Brigham and Women’s Hospital in Boston, said the study confirmed the belief of many physicians, patients, and caregivers that hospital care determines outcomes only within a week or two of discharge. After that period, health outcomes reflect other aspects of patient lives.

“We might need to shift our thinking more broadly to learn how to keep people healthy and out of the hospital in the first place,” Joynt said in an interview.

Adele Shartzer, a researcher for the Urban Institute, said shifting from a 30-day to a seven-day readmission responsibility period may better reflect care delivered at a hospital and also could potentially reduce the role of individual and community-level socioeconomic factors in readmissions penalties.

“But I think we need much more evidence before we initiate such a shift,” Shartzer said in an interview. “It will take time, more evidence and a scientific consensus before reimbursement policy changes.”

However, Eric Schneider, MD, senior vice president of policy and research for The Commonwealth Fund, said shrinking the interval period doesn’t fix the problem of hospitals being unfairly classified compared to their peers.

“I think of HRRP as a transition as we move to an integrated delivery system that includes accountable care organizations (ACOs) and payment bundling,” Schneider said in an interview.

Robert Berenson, MD, a fellow at the Urban Institute and a former member of the Medicare Payment Advisory Commission (MedPAC), said the 30-day interval period has no empirical logic.

“You invite all sorts of problems when you hold hospitals accountable for issues out of their control like a lack of community resources and patient socio-economic status,” Berenson said in an interview.

Berenson pointed out that Congress would have to act to change the HRRP measurements.

Improved Results

A second Health Affairs study, examined how safety-net hospitals have fared under HRRP. The authors found that HRRP has reduced 30-day readmissions in safety-net hospitals, but its penalty assessment formula still needed to be reassessed.

“A frequently voiced concern is related to the program’s impact on safety-net hospitals, whichserve a relatively high proportion of low-income patients and who have a relatively high probability of readmission,” the authors wrote.

In the first three years of the program, safety-net hospitals reduced readmissions for heart attack by 2.86 percentage points, heart failure by 2.78 percentage points, and pneumonia by 1.77 percentage points, while shrinking the disparity between their readmission rates and those of other hospitals.

However, the authors learned that “reducing readmissions may be more challenging for safety-net hospitals than for other hospitals: safety-net institutions have not improved as much as other hospitals that had initial high readmission rates.”

The study results support MedPAC’s approach of modifying the amount of penalties imposed on safety-net hospitals and evaluating them against other safety-net hospitals.

“This would maintain incentives for improvement, but would reduce financial pressure on safety-net hospitals, especially for those with patient populations of the lowest socioeconomic status,” they concluded.

Beth Feldpush, senior vice president for policy and advocacy for America’s Essential Hospitals (AEH), said the study confirmed that safety- net hospitals are unfairly penalized by HRRP quality measures.

“Safety-net hospitals have a harder time on readmission measures because of the characteristics of the communities they serve and the socioeconomic challenges their patients face,” Feldpush said in an interview.

Feldpush said her members were two and one-half times more likely to be penalized under HRRP than other U.S. hospitals.

Safety-net hospitals carry a much larger burden of uncompensated care and much tighter profit margins, Feldpush said, about the average 2014 8 percent average hospital profit margin, compared to AEH hospitals barely breaking even.

Earlier this year the House of Representatives passed legislation that accounted for socioeconomic status when applying penalties under HRRP.

“But in this highly charged political climate and the uncertainty surrounding this election, it’s impossible to predict its chances of passage,” Feldpush said.

Mark Taylor is a freelance writer based in Chicago.

Publication Date: Thursday, October 13, 2016