Dataset Information

The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

ABSTRACT:

Objective

To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations.

Data sources/study setting

Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics.

Study design

Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP.

Principal findings

Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations.

Conclusions

Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations.

SUBMITTER: Gu Q

PROVIDER: S-EPMC4231573 | biostudies-literature | 2014 Jun

REPOSITORIES: biostudies-literature

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Publications

The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

Gu Qian Q Koenig Lane L Faerberg Jennifer J Steinberg Caroline Rossi CR Vaz Christopher C Wheatley Mary P MP

Health services research 20140113 3

<h4>Objective</h4>To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations.<h4>Data sources/study setting</h4>Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics.<h4>Study design</h4>Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penaltie ...[more]

PMID: 24417309

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Project description: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.

Project description:ImportanceExcess 30-day readmissions have declined substantially in hospitals initially penalized for high readmission rates under the Medicare Hospital Readmissions Reduction Program (HRRP). Although a possible explanation is that the policy incentivized penalized hospitals to improve care processes, another is regression to the mean (RTM), a statistical phenomenon that predicts entities farther from the mean in one period are likely to fall closer to the mean in subsequent (or preceding) periods owing to random chance.ObjectiveTo quantify the contribution of RTM to declining readmission rates at hospitals initially penalized under the HRRP.Design, setting, and participantsThis study analyzed data from Medicare Provider and Analysis Review files to assess changes in readmissions going forward and backward in time at hospitals with high and low readmission rates during the measurement window for the first year of the HRRP (fiscal year [FY] 2013) and for a measurement window that predated the FY 2013 measurement window for the HRRP among hospitals participating in the HRRP. Hospital characteristics are based on the 2012 survey by the American Hospital Association. The analysis included fee-for-service Medicare beneficiaries 65 years or older with an index hospitalization for 1 of the 3 target conditions of heart failure, acute myocardial infarction, or pneumonia or chronic obstructive pulmonary disease and who were discharged alive from February 1, 2006, through June 30, 2014, with follow-up completed by July 30, 2014. Data were analyzed from January 23, 2018, through March 29, 2019.ExposuresHospital Readmission Reduction Program penalties.Main outcome and measuresThe excess readmission ratio (ERR), calculated as the ratio of a hospital's readmissions to the readmissions that would be expected based on an average hospital with similar patients. Hospitals with ERRs of greater than 1.0 were penalized.ResultsA total of 3258 hospitals were included in the study. For the 3 target conditions, hospitals with ERRs of greater than 1.0 during the FY 2013 measurement window exhibited decreases in ERRs in the subsequent 3 years, whereas hospitals with ERRs of no greater than 1.0 exhibited increases. For example, for patients with heart failure, mean ERRs declined from 1.086 to 1.038 (-0.048; 95% CI, -0.053 to -0.043; P < .001) at hospitals with ERRs of greater than 1.0 and increased from 0.917 to 0.957 (0.040; 95% CI, 0.036-0.044; P < .001) at hospitals with ERRs of no greater than 1.0. The same results, with ERR changes of similar magnitude, were found when the analyses were repeated using an alternate measurement window that predated the HRRP and followed up hospitals for 3 years (for patients with heart failure, mean ERRs declined from 1.089 to 1.044 [-0.045; 95% CI, -0.050 to -0.040; P < .001] at hospitals with below-mean performance and increased from 0.915 to 0.948 [0.033; 95% CI, 0.029 to 0.037; P < .001] at hospitals with above-mean performance). By comparing actual changes in ERRs with expected changes due to RTM, 74.3% to 86.5% of the improvement in ERRs for penalized hospitals was explained by RTM.Conclusions and relevanceMost of the decline in readmission rates in hospitals with high rates during the measurement window for the first year of the HRRP appeared to be due to RTM. These findings seem to call into question the notion of an HRRP policy effect on readmissions.

Project description:IMPORTANCE:Hospitals that serve poorer populations have higher readmission rates. It is unknown whether these hospitals effectively lowered readmission rates in response to the Hospital Readmissions Reduction Program (HRRP). OBJECTIVE:To compare pre-post differences in readmission rates among hospitals with different proportion of dual-eligible patients both generally and among the most highly penalized (ie, low performing) hospitals. DESIGN:Retrospective cohort study using piecewise linear model with estimated hospital-level risk-standardized readmission rates (RSRRs) as the dependent variable and a change point at HRRP passage (2010). Economic burden was assessed by proportion of dual-eligibles served. SETTING:Acute care hospitals within the United States. PARTICIPANTS:Medicare fee-for-service beneficiaries aged 65 years or older discharged alive from January 1, 2003 to November 30, 2014 with a principal discharge diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. MAIN OUTCOME AND MEASURE:Decrease in hospital-level RSRRs in the post-law period, after controlling for the pre-law trend. RESULTS:For AMI, the pre-post difference between hospitals that service high and low proportion of dual-eligibles was not significant (-65 vs. -64 risk-standardized readmissions per 10000 discharges per year, P=0.0678). For CHF, RSRRs declined more at high than low dual-eligible hospitals (-79 vs. -75 risk-standardized readmissions per 10000 discharges per year, P=0.0006). For pneumonia, RSRRs declined less at high than low dual-eligible hospitals (-44 vs. -47 risk-standardized readmissions per 10000 discharges per year, P=0.0003). Among the 742 highest penalized hospitals and all conditions, the pre-post decline in rate of change of RSRRs was less for high dual-eligible hospitals than low dual-eligible hospitals (-68 vs. -74 risk-standardized readmissions per 10000 discharges per year for AMI, -88 vs. -97 for CHF, and -47 vs. -56 for pneumonia, P<0.0001 for all). CONCLUSIONS AND RELEVANCE:For all hospitals, differences in pre-post trends in RSRRs varied with disease conditions. However, for the highest-penalized hospitals, the pre-post decline in RSRRs was greater for low than high dual-eligible hospitals for all penalized conditions. These results suggest that high penalty, high dual-eligible hospitals may be less able to improve performance on readmission metrics.

Project description:Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient- and procedure-related factors.More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004-2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions.Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively (P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P < .001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality.Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

Project description:ImportanceThe Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population.ObjectiveTo determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race.Design, setting, and participantsIn a cohort study using an interrupted time-series analysis conducted from March 15, 2018, to January 23, 2019, in 3263 eligible acute care hospitals nationally, risk-adjusted mortality rates observed after Medicare started to impose penalties (October 1, 2012, to November 30, 2014) were compared with projections based on pre-HRRP trends (January 1, 2007, to March 31, 2010) among adults 65 years and older with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Observed-to-projected differences were then compared between racial groups.ExposuresHospital discharge during pre-HRRP and HRRP penalty periods.Main outcomes and measuresThirty-day postdischarge all-cause mortality.ResultsIn the 3263 acute care hospitals included in the analysis, black patients (627?373 index discharges) were more likely than white patients (5?845?130 index discharges) to be younger (mean [SD] age, 77.8 [8.3] vs 80.5 [8.2] years; P?<?.001), women (60.5% vs 53.7%; P?<?.001), dually covered by Medicare and Medicaid (45.7% vs 17.2%; P?<?.001), and treated at a penalized hospital (AMI, 82.8%; HF, 83.8%; and pneumonia, 82.6% vs 69.6%; 73.3%; and 71.7%; all P?<?.001). Pre-HRRP mortality rates for black vs white patients were 7.04% (95% CI, 6.75% to 7.33%) vs 7.47% (95% CI, 7.37% to 7.57%) for AMI, 6.69% (95% CI, 6.56% to 6.82%) vs 8.56% (95% CI, 8.48% to 8.64%) for HF, and 8.08% (95% CI, 7.88% to 8.27%) vs 8.27% (95% CI, 8.19% to 8.35%) for pneumonia. By the HRRP penalty period, observed mortality for AMI decreased more, relative to projections, among black than white patients (difference-in-differences, -1.65 percentage points; 95% CI, -3.19 to -0.10; P?=?.04). For HF, mortality increased relative to projections among white patients but not among black patients; however; mortality trends did not differ by race (difference-in-differences, -0.37 percentage points; 95% CI, -1.08 to 0.34; P?=?.31). For pneumonia, observed mortality was similar to projections in both racial groups, and trends did not differ by race (difference-in-differences, -0.54 percentage points; 95% CI, -1.66 to 0.59; P?=?.35). At both penalized and nonpenalized hospitals, mortality trends were similar or decreased more among black patients than white patients.Conclusions and relevanceIn this study of patients 65 years and older, short-term postdischarge mortality did not appear to increase for black patients under the HRRP, suggesting that certain value-based payment policies can be implemented without harming black populations. However, mortality seemed to increase for white patients with HF and this situation warrants investigation.

Dataset Information

The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

Objective

Data sources/study setting

Study design

Principal findings

Conclusions

Publications

The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

Similar Datasets

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