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?
Project description:Importance:Since 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. Objective:To 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 Participants:In 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. Exposures:Nonstratified and stratified Centers for Medicare & Medicaid payment adjustment methods. Main Outcomes and Measures:Net 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). Results:Penalty 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 Relevance:The 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:Background:Whether 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. Objective:To 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. Design:Pre-post analysis stratified by hospital performance groups. Setting:U.S. acute care hospitals. Patients:15 170 008 Medicare patients discharged alive from 2000 to 2013. Intervention:Passage of the HRRP. Measurements:30-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. Results:Of 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. Limitation:Inability to distinguish between improvement caused by the magnitude of the penalty or by different levels of health improvement in different patient populations. Conclusion:After 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 Source:National Institutes of Health.
Project description:Importance:The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. Objective:To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. Design, Setting, and Participants:Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60?663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. Exposures:Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. Main Outcomes and Measures:The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. Results:Among 143 Florida hospitals, 2991 of 60?663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r?=?-0.16, P?=?.06) and HRRP risk-adjusted readmission penalties (r?=?-0.12, P?=?.14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. Conclusions and Relevance:This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.
Project description:BACKGROUND:Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen. OBJECTIVE:To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals. DESIGN:Repeated cross-sectional analysis, stratified by safety-net status. SUBJECTS:1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR. MAIN MEASURES:Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014. KEY RESULTS:Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P?<?0.05). These trends continued following the passage of HRRP. CONCLUSIONS:Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.
Project description:Importance:Although readmission rates are declining under Medicare's Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions. Objective:To examine disparities in readmission rates between white and black patients discharged from safety-net or non-safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions. Design, Setting, and Participants:Cohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non-safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018. Main Outcomes and Measures:Trends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods. Results:The study sample included 58?237?056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50?372?806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P?=?.01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P?=?.006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, -0.07 to 0.10]; P?=?.74). Within non-safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted. Conclusions and Relevance:Findings from this study suggest that disparities are widening within safety-net hospitals, specifically for non-HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.
Project description:<h4>Importance</h4>Beginning in fiscal year 2019, Medicare's Hospital Readmissions Reduction Program (HRRP) stratifies hospitals into 5 peer groups based on the proportion of each hospital's patient population that is dually enrolled in Medicare and Medicaid. The effect of this policy change is largely unknown.<h4>Objective</h4>To identify hospital and state characteristics associated with changes in HRRP-related performance and penalties after stratification.<h4>Design, setting, and participants</h4>A cross-sectional analysis was performed of all 3049 hospitals participating in the HRRP in fiscal years 2018 and 2019, using publicly available data on hospital penalties, merged with information on hospital characteristics and state Medicaid eligibility cutoffs.<h4>Exposures</h4>The HRRP, under the 2018 traditional method and the 2019 stratification method.<h4>Main outcomes and measures</h4>Performance on readmissions, as measured by the excess readmissions ratio, and penalties under the HRRP both in relative percentage change and in absolute dollars.<h4>Results</h4>The study sample included 3049 hospitals. The mean proportion of dually enrolled beneficiaries ranged from 9.5% in the lowest quintile to 44.7% in the highest quintile. At the hospital level, changes in penalties ranged from an increase of $225?000 to a decrease of more than $436?000 after stratification. In total, hospitals in the lowest quintile of dual enrollment saw an increase of $12?330?157 in penalties, while those in the highest quintile of dual enrollment saw a decrease of $22?445?644. Teaching hospitals (odds ratio [OR], 2.13; 95% CI, 1.76-2.57; P?<?.001) and large hospitals (OR, 1.51; 95% CI, 1.22-1.86; P?<?.001) had higher odds of receiving a reduced penalty. Not-for-profit hospitals (OR, 0.64; 95% CI, 0.52-0.80; P?<?.001) were less likely to have a penalty reduction than for-profit hospitals, and hospitals in the Midwest (OR, 0.44; 95% CI, 0.34-0.57; P?<?.001) and South (OR, 0.42; 95% CI, 0.30-0.57; P?<?.001) were less likely to do so than hospitals in the Northeast. Hospitals with patients from the most disadvantaged neighborhoods (OR, 2.62; 95% CI, 2.03-3.38; P?<?.001) and those with the highest proportion of beneficiaries with disabilities (OR, 3.12; 95% CI, 2.50-3.90; P?<?.001) were markedly more likely to see a reduction in penalties, as were hospitals in states with the highest Medicaid eligibility cutoffs (OR, 1.79; 95% CI, 1.50-2.14; P?<?.001).<h4>Conclusions and relevance</h4>Stratification of the hospitals under the HRRP was associated with a significant shift in penalties for excess readmissions. Policymakers should monitor the association of this change with readmission rates as well as hospital financial performance as the policy is fully implemented.
Project description:OBJECTIVE:To compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP). DESIGN:A retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015. SETTING:We examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital's proportion of patients with low socioeconomic status. PARTICIPANTS:Admissions for Medicare fee-for-service patients, age ?65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions. PRIMARY AND SECONDARY OUTCOME MEASURES:Mean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April-June 2010, after HRRP was passed, and October-December 2012, after HRRP penalties were implemented. RESULTS:58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals' patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95%?CI 0.03 to 0.02, p<0.001) greater among safety net hospitals over the entire study period, and no differential change among safety net and non-safety net hospitals was found after either HRRP was passed or penalties enacted. CONCLUSIONS:Since HRRP was passed and penalties implemented, readmission rates for safety net hospitals have decreased more rapidly than those for non-safety net hospitals.
Project description:BACKGROUND:Medicare's Hospital Readmission Reduction Program (HRRP) penalizes hospitals with elevated 30-day readmission rates for acute myocardial infarction (AMI), heart failure (HF), or pneumonia. To reduce readmissions, hospitals may have increased referrals to skilled nursing facilities (SNFs) and home health care. RESEARCH DESIGN:Outcomes included 30-day postdischarge utilization of SNF and home health care, including any use as well as days of use. Subjects included Medicare fee-for-service beneficiaries aged 65 years and older who were admitted with AMI, HF, or pneumonia to hospitals subject to the HRRP. Using an interrupted time-series analysis, we compared utilization rates observed after the announcement of the HRRP (April 2010 through September 2012) and after the imposition of penalties (October 2012 through September 2014) with projected utilization rates that accounted for pre-HRRP trends (January 2008 through March 2010). Models included patient characteristics and hospital fixed effects. RESULTS:For AMI and HF, utilization of SNF and home health care remained stable overall. For pneumonia, observed utilization of any SNF care increased modestly (1.0%, P<0.001 during anticipation; 2.4%, P<0.001 after penalties) and observed utilization of any home health care services declined modestly (-0.5%, P=0.008 after announcement; -0.7%, P=0.045 after penalties) relative to projections. Beneficiaries with AMI and pneumonia treated at penalized hospitals had higher rates of being in the community 30 days postdischarge. CONCLUSIONS:Hospitals might be shifting to more intensive postacute care to avoid readmissions among seniors with pneumonia. At the same time, penalized hospitals' efforts to prevent readmissions may be keeping higher proportions of their patients in the community.
Project description:Importance:The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. Objective:To identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. Design, Setting, and Participants:This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. Exposures:Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. Main Outcomes and Measures:Hospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). Results:Included in the study were 4?884?237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2?608?182 women [53.4%]) and 4?450?378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P?<?.001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.3 [95% CI, 15.1-15.5] vs 15.9 [95% CI, 15.7-16.0]; P?<?.001). A 1% absolute increase in risk-adjusted hospital-level DNR prevalence was associated with greater odds of avoiding HRRP financial penalty (odds ratio, 1.06; 95% CI, 1.04-1.08; P?<?.001). Conclusions and Relevance:This cross-sectional study found that the lack of adjustment in CMS 30-day RSMR and RSRR models for POA DNR status of hospitalized patients may be associated with biased readmission penalization and hospital-level performance.
Project description:BACKGROUND:The Hospital Readmission Reduction Program (HRRP) penalizes hospitals with "excess" readmissions up to 3% of Medicare reimbursement. Approximately 75% of eligible hospitals received penalties, worth an estimated $428 million, in fiscal year 2015. OBJECTIVE:To identify demographic and socioeconomic disparities between matched and localized maximum-penalty and no-penalty hospitals. DESIGN:A case-control study in which cases included were hospitals to receive the maximum 3% penalty under the HRRP during the 2015 fiscal year. Controls were drawn from no-penalty hospitals and matched to cases by hospital characteristics (primary analysis) or geographic proximity (secondary analysis). SETTING:A selectiion of 3383 US hospitals eligible for HRRP. PARTICIPANTS:Thirty-nine case and 39 control hospitals from the HRRP cohort. MEASUREMENTS:Socioeconomic status variables were collected by the American Community Survey. Hospital and health system characteristics were drawn from Centers for Medicare and Medicaid Services, American Hospital Association, and Dartmouth Atlas of Health Care. The statistical analysis was conducted using Student t tests. RESULTS:Thirty-nine hospitals received a maximum penalty. Relative to controls, maximum-penalty hospitals in counties with lower SES profiles are defined by increased poverty rates (19.1% vs 15.5%, ? = 0.015) and lower rates of high school graduation (82.2% vs 87.5%, ? = 0.001). County level age, sex, and ethnicity distributions were similar between cohorts. CONCLUSIONS:Cases were more likely than controls to be in counties with low socioeconomic status; highlighting potential unintended consequences of national benchmarks for phenomena underpinned by environmental factors; specifically, whether maximum penalties under the HRRP are a consequence of underperforming hospitals or a manifestation of underserved communities.