Hospital readmissions penalties now in 5th year

 

With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?

First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,¹ the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.

HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.²

Hospital readmissions were discussed by health policy researchers for years, without much impact on policy, but once there were financial implications, there was more action to improve performance, says Harlan Krumholz, MD, director of the Yale New Haven (Conn.) Health System Center for Outcomes Research and Evaluation and lead researcher on the center’s government contract to develop the 30-day readmission measure used by CMS.³

“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.

“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”

Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.

“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”

HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
 

What have we learned about readmissions in 5 years?

A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.

Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.

A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.

It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
 

 

Impact on working hospitalists

One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.

“It’s an open question what is the accountability of individual hospitalists. No doubt thinking about these issues has changed, but I don’t think that much has really changed for the front line hospitalist. Does what’s written about readmissions translate to what people are feeling on the front lines?” he asked. “I’m a hospitalist, and I wish I could set up all of the services that would be needed by my patient at home. I’d send that patient home today if I could. But that kind of redesign requires a lot deeper thinking about what really happens after the patient goes home.”

Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.

“At the level of the hospitalist group, there can be more skin in the game, but at the level of the doctor who writes the discharge order, it’s more of an individual responsibility to acknowledge their role in making sure that the right steps are taken in the discharge process,” said Brian Harte, MD, SFHM, a past president of the Society of Hospital Medicine, who in 2016 was named president of Cleveland Clinic Akron (Ohio) General Hospital.

“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”

Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.

“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
 

Readmissions at the front lines

Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.

“On the front lines, we’ve definitely seen increased emphasis from our senior leadership, which translates into having more tools and time to work on improving transitions and on teamwork,” he said. The hospital has provided tools for Dr. Talari and his team to participate in Project BOOST, and made sure that each of its 16 hospital medicine teams includes a dedicated case manager and pharmacist. “We’ve also partnered with nursing homes and rehabilitation facilities,” he noted.

“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”

According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
 

Better interventions, better infrastructure

Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”

Dr. Horwitz also sees a growing body of evidence that change is possible, “not only evidence that intervention works, but that it matters if you get medication reconciliation right, if you connect discharged patients with community services. But you have to throw everything at the problem. The studies that look at only one intervention to improve transitions tend to fail,” she said.

“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”

Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.

“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
 

Recent research on readmissions penalties

A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.⁴ The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.

A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.⁵ Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.

Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.⁶

But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.⁷ Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.⁸

More research will be forthcoming from Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence), a $15.5 million initiative funded for 51 months by the Patient Centered Outcomes Research Institute. Led by Mark Williams, MD, FACP, MHM, chief transformation & learning officer and chief of Hospital Medicine at the University of Kentucky and principal investigator for SHM’s Project BOOST, it aims to identify the most effective strategies in delivering to patients and their caregivers what matters most to them in their hospital and discharge experience.

“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
 

References

1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.

2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.

3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.

4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.

5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.

6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.

7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.

8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.

 

With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?

First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,¹ the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.

HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.²

Hospital readmissions were discussed by health policy researchers for years, without much impact on policy, but once there were financial implications, there was more action to improve performance, says Harlan Krumholz, MD, director of the Yale New Haven (Conn.) Health System Center for Outcomes Research and Evaluation and lead researcher on the center’s government contract to develop the 30-day readmission measure used by CMS.³

“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.

“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”

Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.

“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”

HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
 

What have we learned about readmissions in 5 years?

A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.

Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.

A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.

It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
 

 

Impact on working hospitalists

One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.

“It’s an open question what is the accountability of individual hospitalists. No doubt thinking about these issues has changed, but I don’t think that much has really changed for the front line hospitalist. Does what’s written about readmissions translate to what people are feeling on the front lines?” he asked. “I’m a hospitalist, and I wish I could set up all of the services that would be needed by my patient at home. I’d send that patient home today if I could. But that kind of redesign requires a lot deeper thinking about what really happens after the patient goes home.”

Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.

“At the level of the hospitalist group, there can be more skin in the game, but at the level of the doctor who writes the discharge order, it’s more of an individual responsibility to acknowledge their role in making sure that the right steps are taken in the discharge process,” said Brian Harte, MD, SFHM, a past president of the Society of Hospital Medicine, who in 2016 was named president of Cleveland Clinic Akron (Ohio) General Hospital.

“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”

Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.

“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
 

Readmissions at the front lines

Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.

“On the front lines, we’ve definitely seen increased emphasis from our senior leadership, which translates into having more tools and time to work on improving transitions and on teamwork,” he said. The hospital has provided tools for Dr. Talari and his team to participate in Project BOOST, and made sure that each of its 16 hospital medicine teams includes a dedicated case manager and pharmacist. “We’ve also partnered with nursing homes and rehabilitation facilities,” he noted.

“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”

According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
 

Better interventions, better infrastructure

Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”

Dr. Horwitz also sees a growing body of evidence that change is possible, “not only evidence that intervention works, but that it matters if you get medication reconciliation right, if you connect discharged patients with community services. But you have to throw everything at the problem. The studies that look at only one intervention to improve transitions tend to fail,” she said.

“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”

Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.

“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
 

Recent research on readmissions penalties

A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.⁴ The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.

A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.⁵ Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.

Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.⁶

But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.⁷ Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.⁸

More research will be forthcoming from Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence), a $15.5 million initiative funded for 51 months by the Patient Centered Outcomes Research Institute. Led by Mark Williams, MD, FACP, MHM, chief transformation & learning officer and chief of Hospital Medicine at the University of Kentucky and principal investigator for SHM’s Project BOOST, it aims to identify the most effective strategies in delivering to patients and their caregivers what matters most to them in their hospital and discharge experience.

“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
 

References

1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.

2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.

3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.

4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.

5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.

6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.

7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.

8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.

 

With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?

First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,¹ the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.

HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.²

Hospital readmissions were discussed by health policy researchers for years, without much impact on policy, but once there were financial implications, there was more action to improve performance, says Harlan Krumholz, MD, director of the Yale New Haven (Conn.) Health System Center for Outcomes Research and Evaluation and lead researcher on the center’s government contract to develop the 30-day readmission measure used by CMS.³

“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.

“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”

Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.

“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”

HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
 

What have we learned about readmissions in 5 years?

A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.

Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.

A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.

It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
 

 

Impact on working hospitalists

One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.

“It’s an open question what is the accountability of individual hospitalists. No doubt thinking about these issues has changed, but I don’t think that much has really changed for the front line hospitalist. Does what’s written about readmissions translate to what people are feeling on the front lines?” he asked. “I’m a hospitalist, and I wish I could set up all of the services that would be needed by my patient at home. I’d send that patient home today if I could. But that kind of redesign requires a lot deeper thinking about what really happens after the patient goes home.”

Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.

“At the level of the hospitalist group, there can be more skin in the game, but at the level of the doctor who writes the discharge order, it’s more of an individual responsibility to acknowledge their role in making sure that the right steps are taken in the discharge process,” said Brian Harte, MD, SFHM, a past president of the Society of Hospital Medicine, who in 2016 was named president of Cleveland Clinic Akron (Ohio) General Hospital.

“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”

Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.

“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
 

Readmissions at the front lines

Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.

“On the front lines, we’ve definitely seen increased emphasis from our senior leadership, which translates into having more tools and time to work on improving transitions and on teamwork,” he said. The hospital has provided tools for Dr. Talari and his team to participate in Project BOOST, and made sure that each of its 16 hospital medicine teams includes a dedicated case manager and pharmacist. “We’ve also partnered with nursing homes and rehabilitation facilities,” he noted.

“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”

According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
 

Better interventions, better infrastructure

Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”

Dr. Horwitz also sees a growing body of evidence that change is possible, “not only evidence that intervention works, but that it matters if you get medication reconciliation right, if you connect discharged patients with community services. But you have to throw everything at the problem. The studies that look at only one intervention to improve transitions tend to fail,” she said.

“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”

Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.

“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
 

Recent research on readmissions penalties

A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.⁴ The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.

A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.⁵ Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.

Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.⁶

But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.⁷ Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.⁸

More research will be forthcoming from Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence), a $15.5 million initiative funded for 51 months by the Patient Centered Outcomes Research Institute. Led by Mark Williams, MD, FACP, MHM, chief transformation & learning officer and chief of Hospital Medicine at the University of Kentucky and principal investigator for SHM’s Project BOOST, it aims to identify the most effective strategies in delivering to patients and their caregivers what matters most to them in their hospital and discharge experience.

“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
 

References

1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.

2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.

3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.

4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.

5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.

6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.

7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.

8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.