Joynt Maddox, Karen E.

Wadhera, Rishi K.

Yeh, Robert W.

English

Digital Commons@Becker

Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2019The hospital readmissions reduction program —Time for a rebootRishi K. WadheraRobert W. YehKaren E. Joynt MaddoxFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsPERSPECTIVE2289Getting Coverage Right for 500 Million Indiansn engl j med 380;24  nejm.org June 13, 2019likely because they increased ac-cess to poor-quality care. What can India do to demonstrate its commitment to quality? Invest-ments in collecting data in elec-tronic records that systematically measure quality are part of the solution, but we believe that a national program that defines and tracks quality across the spectrum of care is crucial. Be-yond the health benefits of im-proving quality, such programs build trust, encouraging people to return. Without deliberate at-tention to and action on quality, it’s unlikely that the reform will lead to better health outcomes.The Indian health insurance scheme will be studied closely. Five Indian states are opting out of the reform; the reach and suc-cess of Ayushman Bharat will be determined in part by the ability of these states to effectively dem-onstrate that their models are ex-panding access, providing finan-cial protection, and improving health outcomes. Parts of India have health indicators compara-ble to those of southern Europe, while other areas mirror parts of sub-Saharan Africa. No single strategy will work, but India’s di-verse landscape also means that an extraordinary learning oppor-tunity for implementing univer-sal health coverage on a vast scale is unfolding. If the government invests heavily in evaluations, test-ing new approaches, and listening intently to states, it can ensure that relevant lessons are learned.India’s bold step toward reform reflects an increasingly intercon-nected world and the desire of all people to have access to the fruits of modern medicine. From Mexico in 2006, to the United States in 2010, to China in 2016, to India now, universal coverage has become reform’s rallying cry. A high-profile failure, however, will set this movement back. India has the formula to succeed, and we believe the emphases outlined here can help India show the world that health care for all is eminently possible, even in the most complex of circumstances.Disclosure forms provided by the authors are available at NEJM.org.From the Harvard Global Health Institute, Harvard T.H. Chan School of Public Health, Boston. This article was published on May 22, 2019, at NEJM.org.1. Brundtland GH. India’s health reforms: the need for balance. Lancet 2018; 392: 1174-5.2. UN Interagency Group for Child Mortal-ity Estimation. Mortality rate, infant (per 1,000 live births). Washington, DC: World Bank, 2018 (https://data .worldbank .org/ indicator/ SP .DYN .IMRT .IN?name_desc=true).3. Wagstaff A, Flores G, Hsu J, et al. Prog-ress on catastrophic health spending in 133 countries: a retrospective observational study. Lancet Glob Health 2018; 6(2): e169-e179.4. Bell D, Gachuhi N, Assefi N. Dynamic clinical algorithms: digital technology can transform health care decision-making. Am J Trop Med Hyg 2018; 98: 9-14.5. Das J, Holla A, Das V, Mohanan M, Ta-bak D, Chan B. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Aff (Millwood) 2012; 31: 2774-84.DOI: 10.1056/NEJMp1901771Copyright © 2019 Massachusetts Medical Society.Getting Coverage Right for 500 Million IndiansThe Hospital Readmissions Reduction ProgramThe Hospital Readmissions Reduction Program  — Time for a RebootRishi K. Wadhera, M.D., M.P.P., Robert W. Yeh, M.D., and Karen E. Joynt Maddox, M.D., M.P.H. The Hospital Readmissions Re-duction Program (HRRP) was established by the Centers for Medicare and Medicaid Services (CMS) in 2010 with a goal of  reducing preventable hospitaliza-tions by imposing financial pen-alties on hospitals with higher-than-expected 30-day readmission rates. After the program was cre-ated, readmission rates appeared to decrease nationwide for patients hospitalized with heart failure, acute myocardial infarction, and pneumonia, the three conditions it originally targeted.Some policymakers have pushed for the HRRP to be expanded to cover all conditions treated in inpatient settings. Others, includ-ing many clinicians and research-ers, have expressed skepticism regarding the program’s effects and concerns about unintended consequences. These concerns stem from three major limitations of the program.First, the HRRP defines only inpatient hospitalizations — not observation stays or emergency department (ED) visits — as re-admissions, which has artificially inflated estimates of its success. Although readmission rates have decreased for targeted conditions, rates of observation stays and ED visits after inpatient stays have increased; as a result, the pro-portion of patients who return to a hospital within 30 days after discharge has not changed. This blind spot also creates strong in-centives to treat patients in EDs or observation units to avoid re-admissions, even if inpatient hos-pitalization would improve their access to appropriate care. The HRRP also doesn’t include ob-The New England Journal of Medicine Downloaded from nejm.org at Washington University in St. Louis Becker Library on June 24, 2019. For personal use only. No other uses without permission.  Copyright © 2019 Massachusetts Medical Society. All rights reserved. PERSPECTIVE2290The Hospital Readmissions Reduction Programn engl j med 380;24  nejm.org June 13, 2019servation stays as index events, so little is known about postdis-charge outcomes for patients ad-mitted under observation status. Since hospitals vary widely in their use of observation units, excluding these stays may create an uneven playing field for com-paring hospital performance.A second limitation is that the HRRP metric doesn’t account for the competing risk of death. A pa-tient who dies can no longer be readmitted. But because deaths aren’t factored into readmission rates, hospitals that keep more patients alive and therefore dis-charge a sicker group of people may be penalized for having high-er readmission rates rather than rewarded for having good out-comes. This problem is exacer-bated by the fact that penalties for high readmission rates under the HRRP are much larger than penalties for high mortality un-der the Hospital Value-Based Pur-chasing program.Third, risk adjustment of the readmission measure is inade-quate, which encumbers fair com-parisons among hospitals. Re-admission models are notoriously poor at predicting events. Although coexisting conditions such as dia-betes are well captured in risk-adjustment models, factors such as functional status and frailty, which meaningfully improve risk prediction, are not. Health care utilization patterns are also not accounted for in current models. As a result, differences in severity of illness between a person with heart failure who has one brief hospitalization for swollen ankles and another who is repeatedly hospitalized for decompensated heart failure are poorly captured. Because of their relative simplic-ity, current models are also easy to “game.” Growing evidence sug-gests that much of the reported improvement in risk-adjusted re-admission rates that drove early enthusiasm for the program may have been the result of an artifi-cial increase in coded coexisting conditions rather than improve-ments in care quality.Current risk-adjustment mod-els also omit social risk factors that are strongly related to re-admissions, such as poverty, so hospitals tend to be penalized for serving poor and vulnerable patients. Safety-net hospitals are frequently penalized under the HRRP, which results in a transfer of resources away from resource-poor sites. The 21st Century Cures Act implemented a stratifi-cation scheme in the HRRP this year such that hospitals are com-pared only with other facilities that treat Medicare populations with similar poverty levels. This change was associated with a sig-nificant reduction in penalties for safety-net hospitals.Finally, mounting evidence sug-gests that the HRRP may have had unintended consequences, particularly for patients with heart failure. Four independent studies revealed that mortality within 30 days after discharge from a hos-pitalization for heart failure in-creased significantly after imple-mentation of the HRRP relative to earlier trends.1-4 This increase was concentrated among patients who weren’t readmitted, which raises the possibility that greater use of EDs and observation units by hospitals to reduce readmis-sions may adversely affect patients who would benefit from higher-level care.Two studies have come to dif-ferent conclusions, however. One investigation, by the group that developed the readmission mea-sure, found that although 30-day postdischarge mortality among patients with heart failure in-creased after the HRRP was en-acted, changes from previous trends were not statistically sig-nificant.5 A report by the Medicare Payment Advisory Commission showed that raw in-hospital-through-postdischarge mortality among patients with heart fail-ure increased between 2008 and 2016, but risk-adjusted mortality decreased — from 13.6% to 9.4%. In contrast, studies have consis-tently found that mortality among patients hospitalized for myocar-dial infarction has not increased under the HRRP,1,5 which sug-gests that acute conditions may be better suited to the program than chronic conditions such as heart failure.How can we strengthen the HRRP to mitigate potential un-intended consequences and ensure that the program improves care quality and patient outcomes?Rather than using only inpa-tient readmission rates to evalu-ate hospital performance, the HRRP could use a “return-to-hospital” metric that also in-cludes rates of ED visits and ob-servation-unit stays within 30 days after discharge. These outcomes wouldn’t have to be weighted equally. Such a measure would strengthen hospitals’ incentive to focus on improving care transi-tions and postdischarge care to reduce unnecessary returns to the hospital. It would also encourage hospitals to make more consid-ered care decisions for patients who do return and permit a fairer assessment of hospitals’ perfor-mance. Furthermore, treating both inpatient and observation-unit stays as index events could pro-The New England Journal of Medicine Downloaded from nejm.org at Washington University in St. Louis Becker Library on June 24, 2019. For personal use only. No other uses without permission.  Copyright © 2019 Massachusetts Medical Society. All rights reserved. PERSPECTIVE2291The Hospital Readmissions Reduction Programn engl j med 380;24  nejm.org June 13, 2019vide a more comprehensive pic-ture of hospital-based encounters after discharge.In addition, we believe the metric used in the HRRP should account for the competing risk of death, both during and after hospitalization. One potential ap-proach would be to evaluate per-formance during the period pa-tients are alive within 30 days after discharge. Another possibil-ity would be to create a joint out-come measure that combines hos-pital returns and deaths within 30 days. CMS could also ensure that financial incentives to reduce mortality are greater than incen-tives to reduce readmissions.The HRRP’s risk-adjustment methods could also be improved. The evidence that social risk fac-tors influence readmission rates is incontrovertible. Directly adjust-ing for dual-enrollment status (coverage under both Medicare and Medicaid) in risk models would allow all hospitals to re-ceive similar “credit” for caring for vulnerable patients. Although dual status is a somewhat limit-ed measure of social risk, a grow-ing body of evidence suggests that adding more detailed social-risk data adds little to risk pre-diction. On the other hand, adding covariates such as prior hospital utilization, functional status, and frailty meaningfully improves risk models, particularly for poor and disabled populations. By focus-ing on more holistic risk adjust-ment, such changes might also make the metric less gameable.In the long run, CMS could consider using revenue generat-ed from the HRRP to assist  resource-poor hospitals that con-sistently have high readmission rates in improving discharge plan-ning or care coordination ser-vices. Since many factors that drive readmissions act outside hospital walls, assistance might be most valuable if used to im-prove postdischarge primary and specialty care, address social de-terminants of health, and create linkages between hospitals and community partners. Pairing pen-alties with resources to encour-age implementation of innovative programs focused on resource-poor settings could help ensure that the HRRP’s net effect is pos-itive.More broadly, the ongoing de-bate about the HRRP underscores the consequences of implement-ing national policies with no con-trol group and no plan for itera-tive improvement. For this reason, we believe any change to the HRRP should be made in the context of a robust evaluation effort to determine its effect on patient experience, care quality, and outcomes. Throughout the process, we believe it is impera-tive that policymakers seek input from frontline clinicians and pa-tients who understand the real-world effects of this program. Together, these improvements could reboot the HRRP and trans-form it from a regressive penalty program to a progressive pro-gram that improves patient care.Disclosure forms provided by the authors are available at NEJM.org.From the Richard and Susan Smith Center for Outcomes Research in Cardiology, Divi-sion of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School (R.K.W., R.W.Y.), and the Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School (R.K.W.) — both in Boston; and the Department of Medicine, Cardiovascular Division, Wash-ington University School of Medicine, St. Louis (K.E.J.M.). This article was published on May 15, 2019, at NEJM.org.1. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumo-nia. JAMA 2018; 320: 2542-52.2. Huckfeldt P, Escarce J, Sood N, Yang Z, Popescu I, Nuckols T. Thirty-day postdis-charge mortality among black and white patients 65 years and older in the Medicare Hospital Readmissions Reduction Program. JAMA Netw Open 2019; 2(3): e190634.3. Gupta A, Allen LA, Bhatt DL, et al.  Association of the Hospital Readmissions Reduction Program implementation with re-admission and mortality outcomes in heart failure. JAMA Cardiol 2018; 3: 44-53.4. Huckfeldt P, Escarce J, Wilcock A, et al. HF mortality trends under Medicare Re-admissions Reduction Program at penalized and nonpenalized hospitals. J Am Coll Car-diol 2018; 72: 2539-40.5. Khera R, Dharmarajan K, Wang Y, et al. Association of the Hospital Readmissions Reduction Program with mortality during and after hospitalization for acute myocar-dial infarction, heart failure, and pneumo-nia. JAMA Netw Open 2018; 1(5): e182777.DOI: 10.1056/NEJMp1901225Copyright © 2019 Massachusetts Medical Society.The Hospital Readmissions Reduction ProgramThe New England Journal of Medicine Downloaded from nejm.org at Washington University in St. Louis Becker Library on June 24, 2019. For personal use only. No other uses without permission.  Copyright © 2019 Massachusetts Medical Society. All rights reserved. 

The hospital readmissions reduction program — Time for a reboot

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The hospital readmissions reduction program — Time for a reboot

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