Measuring the readmission measures

Penalties positive step but should evolve into focus on value-based care, experts say.

Three years after its launch, Medicare's Hospital Readmission Reduction Program (HRRP) is generally considered a success. Studies suggest that the program—which penalizes hospitals for excessive readmissions within 30 days of discharge—is working as intended, and experts point to the steady decline in national Medicare readmission rates since 2012.

Although some tweaks may be needed, the HRRP is a positive force in the marketplace, said Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies and co-founder of the State Action on Avoidable Rehospitalizations initiative of the Institute for Healthcare Improvement. Focusing attention on readmissions, she said, forces hospitals to reexamine how they deliver care in general.

Photo by Thinkstock
Photo by Thinkstock

“The whole point of the penalties is to move hospitals toward delivering patient-centered care in the right setting without relying on avoidable hospital use,” she said. “From that standpoint, almost every hospital in America has opportunities to improve.”

Concerns that hospitals might try to work around the penalties—by admitting returning patients to observation care or treating them as outpatients in the ED, for example—have turned out to be largely unfounded, according to a study of New York hospitals published in the June Health Affairs.

“We looked at strategies that hospitals could potentially use to continue to treat Medicare patients in a way that would not affect their score under HRRP,” said the study's lead author, Kathleen Carey, PhD, professor in the department of health law, policy, and management at Boston University's School of Public Health. “We found evidence that observation care was higher than [in] a control group for Medicare patients readmitted following hospitalization for heart attack, but for the most part we did not find strong evidence of unintended effects.”

However, other experts contend that the program unfairly penalizes safety net hospitals, which typically care for Medicare-Medicaid enrollees or “dual eligibles,” who tend to be poorer and have greater health care needs than other Medicare beneficiaries.

“Hospitals serving more disadvantaged patients are getting disproportionately penalized because we are not taking into account complexities that are out of the hospital's control,” said Michael Barnett, MD, an internist at Brigham and Women's Hospital in Boston and coauthor of a study examining the relationship between patient characteristics and readmission rates, published online Sept. 14 by JAMA Internal Medicine. “It appears that the bar is set much higher for safety net hospitals than other hospitals that don't have the same challenges.”

Opinions vary on whether the HRRP needs to be revised or even phased out as government and private payers move toward value-based reimbursement, but most experts agree that it isn't going away any time soon. In the meantime, hospitalists must grapple with how to minimize penalties without jeopardizing quality of care.

Pros and cons

HRRP moves hospitals in the right direction, said Dr. Barnett, but the formula Medicare currently uses to calculate penalties is inherently flawed. It rightly incentivizes hospitals to pay attention to readmissions and high-risk patients but does not take into account many potentially important risk factors for readmission.

Under HRRP, a hospital's annual reimbursement rate can be cut by up to 3% if its actual 30-day readmission rate for Medicare patients is higher than expected based on historical national averages. The program initially targeted readmissions for congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia; chronic obstructive pulmonary disease (COPD) and total hip and knee replacements were added in 2015.

The formula adjusts for patients' age, sex, discharge diagnosis, and recent diagnoses, but many other factors that influence risk of readmission are left out, according to the study in JAMA Internal Medicine.

For that study, Dr. Barnett and his colleagues used national survey and claims data to find 29 other social and clinical risk factors for 30-day readmission. When those were included in the model used to calculate expected readmission rates, the difference between worst- and best-performing hospitals fell by almost 50% compared to the adjustments made by Medicare.

“Safety net hospitals may divert resources from other programs in order to focus on readmission reduction, but they would still end up getting penalized because some factors are out of their control,” Dr. Barnett said. “As a result, 90% of the hospitals penalized this year were also penalized last year.”

It's a downward spiral that has the potential to hurt patients as much as the hospitals that serve them, said Tina Shah, MD, MPH, ACP Resident/Fellow Member, a coauthor of a study published in CHEST in May finding that dual eligibles are more likely than other beneficiaries to be readmitted for COPD.

“These are the patients we really need to take care of, because they are the sickest and most vulnerable, but the places where they receive the most care are also the most vulnerable to feeling the effect of these penalties,” said Dr. Shah, a fellow in the department of pulmonary and critical care at the University of Chicago Medicine.

Preventing COPD readmissions among poorer, sicker, and less educated patients presents unique challenges for safety net hospitals, Dr. Shah and her colleagues noted in the study. For example, up to 85% of patients with COPD misuse their metered-dose inhalers, which is related to poor health literacy.

“Because bronchodilators are a treatment cornerstone, it may be more difficult to improve health and avoid readmission in dually eligible beneficiaries admitted for COPD than in those admitted for CHF, AMI, or pneumonia,” the authors wrote. “Socioeconomic characteristics, including limited social support and financial hardship, could further impede hospital care efforts post-discharge.”

A more evenhanded approach to the readmissions problem would be to tie financial incentives to improvements rather than to compare everyone to a national average, said Dr. Barnett.

Changes to the formula may be on the horizon. According to CMS’ website, the agency is continuing to assess the impact of socioeconomic status on its quality programs and is awaiting the outcome of investigations by the National Quality Forum and the Office of the Assistant Secretary of Planning and Evaluation.

Changing practice

For hospitalists, the best strategy is to focus on improving the overall health of patients, with the idea that fewer readmissions will follow, experts said. But there are also some specific steps they can take to target the goal of fewer readmissions.

“This is a specific, actionable, measurable challenge,” said Dr. Boutwell, a principal investigator of the Hospital Guide to Reducing Medicaid Readmissions, commissioned by the Agency for Healthcare Research and Quality (see sidebar). “It's possible for providers to make a difference by making individual practice changes.”

For example, hospitalists can influence whether a patient is readmitted by collaborating with physicians in the ED, she said.

“As hospitalists, we may be able to offer an alternative plan, such as home follow-up,” said Dr. Boutwell. “Extremely valuable information, such as the family's wishes, often gets lost in the transition from the ED to the medical units. Part of updating our thinking about readmissions is to remember that it all starts in the ED.”

Dr. Boutwell and others also recommended these strategies:

  • Consider readiness for discharge. A study led by Dr. Carey, published in the July Health Economics, found that longer length of stay is associated with lower risk of readmission for patients admitted for heart attack. “For some patients who are unstable, it may be more cost-effective to keep them in the hospital for an extra day if there is a high probability of them being readmitted,” she said.
  • Collect data. The University of Chicago Medicine looks at population-level data to identify patients most likely to be readmitted for COPD, said Dr. Shah. “We intervene in the hospital and follow them for 30 days post-discharge to see what happens,” she said. “Reviewing those trends on a monthly basis guides us as to how well we are taking care of these patients.”
  • Talk to patients. Inform older adult patients and their families about the risks and benefits of hospitalization, said Dr. Boutwell. “They should know that you are happy to take care of them but that the hospital isn't always the safest place to be to care for chronic conditions.”
  • Communicate with outpatient clinicians. “The handoff is very important,” said Dr. Carey. “A phone call between the hospitalist and the PCP has a big impact on what happens after discharge.”

As value-based care takes hold, incentive programs will evolve and take a more multifaceted approach to preventing rehospitalizations, predicted Dr. Barnett. Newer payment models offer a menu of quality measurements, he noted, and leave it up to individual hospitals to prioritize them in a way that both saves money and improves quality of care.

“The HRRP was a novel idea and it met a desperate need for hospitals to focus on the problem of early readmissions,” he said. “But what we need going forward is a broader focus on improving the health of patients.”