Are 30-Day Readmission Rules Deadly for Patients?

Leigh Page

Disclosures

September 03, 2019

Penalties are based on a median level of readmissions, which is updated every year. There is no monetary reward for performing well in the program. Hospitals are not penalized if their readmission rate is below the median, but if they are above the median, they pay a penalty of 1%-3%, depending on what their level of readmissions is.

Hospitals have taken a big financial hit from the program. Since HRRP began, they have paid out nearly $2.5 billion in penalties. In fiscal year 2017, penalized hospitals paid an average penalty of 0.74% of Medicare income, but only 1.8% of hospitals were subject to the maximum penalty of 3%.

The Cons of HRRP

"The readmission penalties were always a terrible, terrible idea," says Steffie Woolhandler, MD, a professor at the City University of New York School of Urban Public Health at Hunter College in New York City.

Unlike MedPAC, Woolhandler believes that only a small share of readmissions is truly preventable. "Patients with frequent readmissions are usually very, very sick," she says. "We knew from the start that penalizing hospitals on the basis of some percentage of readmissions was not fair and was going to cause problems."

The program concerned cardiologists in particular, because two of the three initial measures are in that field.

"Right from the start, many cardiologists were especially concerned about heart failure," Wadhera says. "Heart failure is a chronic condition, where patients can get sicker and require more hospitalization. You cannot always predict when they might need to be readmitted."

The formula for the HRRP penalty tries to account for sicker patients, such as those with heart failure, by applying a risk adjustment. This factor reduces but does not eliminate the penalty for sick patients who are readmitted.

In 2018, the American College of Cardiology urged CMS to consider whether the heart failure measure "should remain as part of HRRP, or any quality program."

But CMS has retained the heart failure measure. One reason for making heart failure one of the initial conditions is that these patients are readmitted more than any other group and thus might be a good target for a readmission reduction.

Besides heart failure, "there is no other group that has a 1 in 4 risk of being readmitted within 30 days," Krumholz said in a 2014 interview. He pointed to a study finding that 16.5% of all readmissions were for heart failure.

Which Studies Capture the True Situation?

Researchers have been on the lookout for an increase in mortality for patients with HRRP conditions.

A 2018 study by Krumholz's group found a slight rise in mortality for heart failure and pneumonia but concluded that this trend existed before HRRP started.

Furthermore, "we know that hospitals that tended to reduce readmission also reduced mortality," Krumholz says. "So if there is excess mortality, it must be concentrated in hospitals that did not reduce readmission."

However, a study by Wadhera and colleagues, released in December, did link the HRRP to a rise in mortality for heart failure and pneumonia. It was based on Medicare claims data, just like the Krumholz group's study.

Wadhera and colleagues found that since HRRP started, postdischarge deaths increased by 0.25% for patients hospitalized with heart failure and by 0.40% for patients with pneumonia.

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