Financial Penalties Seem to Curb All HF Readmissions, Not Just Those Penalized

Debra L Beck

March 05, 2019

Thirty-day heart failure (HF) readmissions fell after the announcement of the Hospital Readmissions Reduction Program (HRRP), but so did readmissions for patients with HF who were admitted for other causes, a new study suggests.

Risk-adjusted acute HF 30-day readmissions declined after passage of the Affordable Care Act (ACA) in 2010 by an absolute 1.09% per year. Meanwhile, other HF-related readmissions also declined 1.05% to 1.24% per year during the same time period (see Central Illustration, below).

"We wanted to see if there was a spillover effect from the HRRP to readmission in patients with heart failure who were hospitalized for other reasons," Saul Blecker, MD, MHS, New York University School of Medicine, NYU Langone Health, New York City, theheart.org | Medscape Cardiology.

"And what we found was that there seems to be more of a global reduction in readmissions that is not just limited to the things that carry a payment penalty."

Their findings are published online March 4 in the Journal of the American College of Cardiology.

To see the effects of HRRP on readmissions, the authors examined readmissions trends during three periods: before the passage of the ACA in March 2010 (cohort 1), after ACA passage but before HRRP penalties started in September 2012 (cohort 2), and from September 2012 to May 2015 (cohort 3). Readmission rates were similar throughout the period for all three cohorts.

Over the approximately 2.5 years between ACA passage and the implementation of HRRP penalties there was about a 3% absolute decline in readmissions for all HF-related reasons.

Unfortunately for proponents of value-based medicine, HF-related readmissions were trending lower even before the passing of the ACA legislation and appeared to stabilize in October 2012 when the financial penalties finally kicked in.

"It seems it was really the announcement of the HRRP, rather than its actual implementation, that caused the decrease," said Blecker, who added that the reductions in readmissions seen before the ACA were small and may have been related to other population changes.

"It's possible that hospitals were able to get to the lowest hanging fruit early on and then past that point, it became more difficult to make substantive further changes," he suggested.

Given that 30-day HF readmission rates remain above 20%, there is still room for improvement.

The HRRP authorized as part of the ACA in 2010 reduces payments to hospitals with higher-than-expected 30-day readmissions following hospitalization for HF, acute myocardial infarction (AMI), and pneumonia.

Blecker and colleagues retrospectively studied 12,973,853 Medicare hospitalizations with a principal or secondary diagnosis of HF between January 2008 and June 2015.

The HRRP 30-day readmission rules apply only to hospitalization with HF as a principal diagnosis, not those with another principal diagnosis (such as COPD or kidney disease) and a secondary diagnosis of HF. The authors separated out hospitalizations with a principal diagnosis of pneumonia or AMI because these conditions are also targeted by HRRP readmission penalties.

More than three-fourths of Medicare hospitalization with a diagnosis of HF fall into this category of non-HRRP covered readmissions, making this secondary reduction particularly noteworthy.

In an editorial, Greg C. Fonarow, MD, Ronald Reagan UCLA Medical Center, Los Angeles, and Boback Ziaeian, MD, PhD, David Geffen School of Medicine, UCLA, write that: "The current distinction of primary or secondary discharge diagnoses is largely arbitrary, and better identification of a cohort of hospitalized patients with HF who benefit from quality improvement efforts is needed."

Fonarow has been a vocal opponent of the HRRP legislation, writing on Twitter that HRRP should be discontinued and that health-policy changes should not be implemented or expanded until they are prospectively evaluated with the same rigor clinical interventions face.

Recent studies have suggested that the magnitude of reduction in readmissions credited to HRRP might be overstated and that implementation of the policy might be associated with increased mortality among patients admitted with heart failure and pneumonia.

This study was supported by grants from the Agency for Healthcare Research and Quality. Blecker reports he has received consulting fees from Medtronic outside of the submitted work. Disclosures for coauthors appear in the paper. Fonarow has received research support from the National Institutes of Health and is a consultant for Abbott, Amgen, Bayer, Janssen, Medtronic, and Novartis. Ziaeian has received support from the American Heart Association.

J Am Coll Cardiol. Published online March 4, 2019. Abstract, Editorial

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