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Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions.

ABSTRACT: Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.Hospital penalty status or target condition under the HRRP.Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.The study included 48?137?102 hospitalizations of 20?351?161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -1.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P?

SUBMITTER: Desai NR

PROVIDER: S-EPMC5599851 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions.

Desai Nihar R NR Ross Joseph S JS Kwon Ji Young JY Herrin Jeph J Dharmarajan Kumar K Bernheim Susannah M SM Krumholz Harlan M HM Horwitz Leora I LI

JAMA 20161201 24

<h4>Importance</h4>Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.<h4>Objective</h4>To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.<h4>Design, setting, and participants</h4>Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 y ...[more]

PMID: 28027367

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Project description:ImportanceSince the introduction of the Hospital Readmission Reduction Program (HRRP), readmission penalties have been applied disproportionately to institutions that serve low-income populations. To address this concern, the US Centers for Medicare & Medicaid introduced a new, stratified payment adjustment method in fiscal year (FY; October 1 to September 30) 2019.ObjectiveTo determine whether the introduction of a new, stratified payment adjustment method was associated with an alteration in the distribution of penalties among hospitals included in the HRRP.Design, setting, and participantsIn this retrospective cross-sectional study, US hospitals included in the HRRP for FY 2018 and FY 2019 were identified. Penalty status of participating hospitals for FY 2019 was determined based on nonstratified HRRP methods and the new, stratified payment adjustment method. Hospitals caring for the highest proportion of patients enrolled in both Medicare and Medicaid based on quintile were assigned to the low-socioeconomic status (SES) group.ExposuresNonstratified and stratified Centers for Medicare & Medicaid payment adjustment methods.Main outcomes and measuresNet reclassification of penalties among all hospitals and hospitals in the low-SES group, in states participating in Medicaid expansion, and for 4 targeted medical conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia).ResultsPenalty status by both payment adjustment methods (nonstratified and stratified) was available for 3173 hospitals. For FY 2019, the new, stratified payment method was associated with penalties for 75.04% of hospitals (2381 of 3173), while the old, nonstratified method was associated with penalties for 79.07% (2509 hospitals), resulting in a net down-classification in penalty status for all hospitals by 4.03 percentage points (95% CI, 2.95-5.11; P < .001). For the 634 low-SES hospitals in the sample, the new method was associated with penalties for 77.60% of hospitals (492 of 634), while the old method was associated with penalties for 91.64% (581 hospitals), resulting in a net down-classification in penalty status of 14.04 percentage points (95% CI, 11.18-16.90; P < .001). Among hospitals that were not low SES (quintiles 1-4), the new payment method was associated with a small decrease in penalty status (1928 vs 1889; net down-classification, 1.54 percentage points; 95% CI, 0.38-2.69; P = .01). Among target medical conditions, the greatest reduction in penalties was observed among cardiovascular conditions (net down-classification, 6.18 percentage points; 95% CI, 4.96-7.39; P < .001).Conclusions and relevanceThe new, stratified payment adjustment method for the HRRP was associated with a reduction in penalties across hospitals included in the program; the greatest reductions were observed among hospitals in the low-SES group, lessening but not eliminating the previously unbalanced penalty burden carried by these hospitals. Additional public policy research efforts are needed to achieve equitable payment adjustment models for all hospitals.

Project description:BackgroundWhether hospitals with the highest risk-standardized readmission rates (RSRRs) subsequently experienced the greatest improvement after passage of the Medicare Hospital Readmissions Reduction Program (HRRP) is unknown.ObjectiveTo evaluate whether passage of the HRRP was followed by acceleration in improvement in 30-day RSRRs after hospitalizations for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia and whether the lowest-performing hospitals had faster acceleration in improvement after passage of the law than hospitals that were already performing well.DesignPre-post analysis stratified by hospital performance groups.SettingU.S. acute care hospitals.Patients15 170 008 Medicare patients discharged alive from 2000 to 2013.InterventionPassage of the HRRP.Measurements30-day readmission rates after hospitalization for AMI, CHF, or pneumonia for hospitals in the highest-performance (0% penalty), average-performance (>0% and <0.50% penalty), low-performance (≥0.50% and <0.99% penalty), and lowest-performance (≥0.99% penalty) groups.ResultsOf 2868 hospitals serving 1 109 530 Medicare discharges annually, 30.1% were highest performers, 44.0% were average performers, 16.8% were low performers, and 9.0% were lowest performers. After controlling for prelaw trends, an additional 67.6 (95% CI, 66.6 to 68.4), 74.8 (CI, 74.0 to 75.4), 85.4 (CI, 84.0 to 86.8), and 95.1 (CI, 92.6 to 97.5) readmissions per 10 000 discharges were found to have been averted per year in the highest-, average-, low-, and lowest-performance groups, respectively, after passage of the law.LimitationInability to distinguish between improvement caused by the magnitude of the penalty or by different levels of health improvement in different patient populations.ConclusionAfter passage of the HRRP, 30-day RSRRs for myocardial infarction, heart failure, and pneumonia decreased more rapidly than before the law's passage. Improvement was most marked for hospitals with the lowest prelaw performance.Primary funding sourceNational Institutes of Health.

Project description:ImportanceMedicare is experimenting with numerous concurrent reforms aimed at improving quality and value for hospitals. It is unclear if these myriad reforms are mutually reinforcing or in conflict with each other.ObjectiveTo evaluate whether hospital participation in voluntary value-based reforms was associated with greater improvement under Medicare's Hospital Readmission Reduction Program (HRRP).Design, setting, and participantsRetrospective, longitudinal study using publicly available national data from Hospital Compare on hospital readmissions for 2837 hospitals from 2008 to 2015. We assessed hospital participation in 3 voluntary value-based reforms: Meaningful Use of Electronic Health Records; the Bundled Payment for Care Initiative episode-based payment program (BPCI); and Medicare's Pioneer and Shared Savings accountable care organization (ACO) programs. We used an interrupted time series design to test whether hospitals' time-varying participation in these value-based reforms was associated with greater improvement in Medicare's HRRP.Main outcomes and measuresThirty-day risk standardized readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia.ResultsAmong the 2837 hospitals in this study, participation in value-based reforms varied considerably over the study period. In 2010, no hospitals were participating in the meaningful use, ACO, or BPCI programs. By 2015, only 56 hospitals were not participating in at least 1 of these programs. Among hospitals that did not participate in any voluntary reforms, the association between the HRRP and 30-day readmission was -0.76 percentage points for AMI (95% CI, -0.93 to -0.60), -1.30 percentage points for heart failure (95% CI, -1.47 to -1.13), and -0.82 percentage points for pneumonia (95% CI, -0.97 to -0.67). Participation in the meaningful use program alone was associated with an additional change in 30-day readmissions of -0.78 percentage points for AMI (95% CI, -0.89 to -0.67), -0.97 percentage points for heart failure (95% CI, -1.08 to -0.86), and -0.56 percentage points for pneumonia (95% CI, -0.65 to -0.47). Participation in ACO programs alone was associated with an additional change in 30-day readmissions of -0.94 percentage points for AMI (95% CI, -1.29 to -0.59), -0.83 percentage points for heart failure (95% CI, -1.26 to -0.41), and -0.59 percentage points for pneumonia (95% CI, -1.00 to -0.18). Participation in multiple reforms led to greater improvement: participation in all 3 programs was associated with an additional change in 30-day readmissions of -1.27 percentage points for AMI (95% CI, -1.58 to -0.97), -1.64 percentage points for heart failure (95% CI, -2.02 to -1.26), and -1.05 percentage points for pneumonia (95% CI, -1.32 to -0.78).Conclusions and relevanceHospital participation in voluntary value-based reforms was associated with greater reductions in readmissions. Our findings lend support for Medicare's multipronged strategy to improve hospital quality and value.

Project description:BackgroundHospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014.ObjectiveWe sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients.DesignWe analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016).PatientsWe assessed discharged patients ≥ 40 years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database.InterventionsHRRP was announced and implemented during this period, forming a natural experiment.MeasurementsWe calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions.Key resultsCOPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions).ConclusionsIn Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.

Project description:ImportanceThe Hospital Readmissions Reduction Program publicly reports and financially penalizes hospitals according to 30-day risk-standardized readmission rates (RSRRs) exclusively among traditional Medicare (TM) beneficiaries but not persons with Medicare Advantage (MA) coverage. Exclusively reporting readmission rates for the TM population may not accurately reflect hospitals' readmission rates for older adults.ObjectiveTo examine how inclusion of MA patients in hospitals' performance is associated with readmission measures and eligibility for financial penalties.Design, setting, and participantsThis is a retrospective cohort study linking the Medicare Provider Analysis and Review file with the Healthcare Effectiveness Data and Information Set at 4070 US acute care hospitals admitting both TM and MA patients. Participants included patients admitted and discharged alive with a diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia between 2011 and 2015. Data analyses were conducted between April 1, 2018, and November 20, 2020.ExposuresAdmission to an acute care hospital.Main outcomes and measuresThe outcome was readmission for any reason occurring within 30 days after discharge. Each hospital's 30-day RSRR was computed on the basis of TM, MA, and all patients and estimated changes in hospitals' performance and eligibility for financial penalties after including MA beneficiaries for calculating 30-day RSRRs.ResultsThere were 748 033 TM patients (mean [SD] age, 76.8 [83] years; 360 692 [48.2%] women) and 295 928 MA patients (mean [SD] age, 77.5 [7.9] years; 137 422 [46.4%] women) hospitalized and discharged alive for AMI; 1 327 551 TM patients (mean [SD] age, 81 [8.3] years; 735 855 [55.4%] women) and 457 341 MA patients (mean [SD] age, 79.8 [8.1] years; 243 503 [53.2%] women) for CHF; and 2 017 020 TM patients (mean [SD] age, 80.7 [8.5] years; 1 097 151 [54.4%] women) and 610 790 MA patients (mean [SD] age, 79.6 [8.2] years; 321 350 [52.6%] women) for pneumonia. The 30-day RSRRs for TM and MA patients were correlated (correlation coefficients, 0.31 for AMI, 0.40 for CHF, and 0.41 for pneumonia) and the TM-based RSRR systematically underestimated the RSRR for all Medicare patients for each condition. Of the 2820 hospitals with 25 or more admissions for at least 1 of the outcomes of AMI, CHF, and pneumonia, 635 (23%) had a change in their penalty status for at least 1 of these conditions after including MA data. Changes in hospital performance and penalty status with the inclusion of MA patients were greater for hospitals in the highest quartile of MA admissions.Conclusions and relevanceIn this cohort study, the inclusion of data from MA patients changed the penalty status of a substantial fraction of US hospitals for at least 1 of 3 reported conditions. This suggests that policy makers should consider including all hospital patients, regardless of insurance status, when assessing hospital quality measures.

Dataset Information

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions.

Publications

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions.

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