Federal program aimed at reducing readmissions raises concerns

The federal Hospital Readmissions Reduction Program (HRRP), aimed at reducing readmission rates, has been linked to an increase in death rates among Medicare patients hospitalized with heart failure, according to a study published in JAMA Cardiology.

The HRRP was established by a provision in the ACA. Under this program, hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia. 

Gupta

“A policy focus on reducing readmissions in heart failure by penalizing hospitals is misguided,” says lead study author Ankur Gupta, MD, PhD, cardiovascular research fellow, Brigham and Women’s Hospital. “Managed healthcare is about reducing cost of healthcare delivery while improving the quality. Therefore, it is extremely important to monitor the effect of a major healthcare policy on not only reducing utilization metric-such as readmission rates in this case-but also its effects on quality of care, patient safety and hard patient outcomes.”

Using the American Heart Association’s Get With The Guidelines-Heart Failure registry data linked to Medicare data, Gupta and colleagues analyzed data in 115,245 fee-for-service Medicare beneficiaries hospitalized with heart failure at 416 hospital sites across the United States using rigorous interrupted time-series and survival analyses accounting for within hospital clustering of patients.

Implementation of the HRRP was associated with a subsequent decrease in 30-day risk-adjusted readmissions from 20.0% to 18.4% and an increase in 30-day risk-adjusted mortality from 7.2% to 8.6%. The findings were similar for one-year readmissions and mortality, according to the authors.

“A policy focus on reducing readmissions in heart failure has raised concerns for unintended consequences of the policy especially on mortality,” says Gupta. “Concerns have been raised about this policy incentivizing ‘gaming’ of the system such as inappropriate triage strategies in emergency departments, delaying readmission beyond discharge day 30 after heart failure hospitalization, and increasing observation stays, among others.” 

Gupta wants to encourage managed care executives to advocate on behalf of heart failure patients to their local representatives to ask CMS to urgently reconsider this policy in heart failure population. “Further, they should monitor these trends of readmissions and mortality in heart failure patients under their managed care and take corrective action as appropriate if notice increasing risk-adjusted mortality in heart failure,” he says.