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Does CMS Need to Dramatically Rethink Readmissions Reduction?

October 17, 2016
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Two new Health Affairs studies examine assumptions about hospital readmissions reduction

Two new studies whose findings have been published as articles in the October issue of Health Affairs are implicitly challenging two fundamental assumptions undergirding the federal Hospital Readmissions Reduction Program (HRRP), which the Centers for Medicare and Medicaid Services (CMS) manages under terms of the Affordable Care Act (ACA). That program, which is being used, with payment reductions for the poorest-performing U.S. hospitals, is mandatory for all Medicare-participating inpatient hospitals, and the levels of penalties for poorly performing hospitals are rising every fiscal year.

Meanwhile, the two articles are questioning two fundamental assumptions about how the program is architected. The first article, entitled “Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care,” was written by a team of researchers: David L. Chin, Heejung Bang, Raj J. Manickam, and Patrick S. Romano; and those researchers conclude that the HRRP needs to shift away from a broad focus on 30-day readmissions, and instead look at the differences in readmissions during the first seven days following discharge, where they found dramatic variations in readmission, variations that they found leveled off tremendously as the 30-day timeframe approached a close. The second article, entitled “Hospital Readmissions Reduction Program: Safety-Net Hospitals Show Improvement, Modifications To Penalty Formula Still Needed,” by Kathleen Carey and Men-Yun Lin, looked at the readmissions reduction results among hospitals that the researchers determined to be safety-net hospitals, and those researchers conclude that CMS needs to drastically change the parameters of its HRRP, in order to account for the dramatically more compromised socioeconomic status of many patients in safety-net hospitals, in order both to be fair to those hospitals, and to adjust the program in order to achieve better outcomes overall.

So, let’s sort through some of what both teams of researchers have found, around the Medicare readmissions reduction program. As the team of researchers noted in the abstract for the first article, “Public reporting and payment programs in the United States have embraced thirty-day readmissions as an indicator of between-hospital variation in the quality of care, despite limited evidence supporting this interval. We examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The hospital-level quality signal captured in readmission risk was highest on the first day after discharge and declined rapidly until it reached a nadir at seven days,” Chin et all noted. “The rapid decay in the quality signal,” the added suggest that most readmissions after the seventh day post-discharge were explained by community- and household-level factors beyond hospitals’ control. Shorter intervals of seven or fewer days might improve the accuracy and equity of readmissions as a measure of hospital quality for public accountability,” they conclude.

Getting down to the specifics of their analysis, David L. Chin et al state this: “The CMS condition-specific technical reports state: ‘Outcomes occurring within 30 days… can be influenced by hospital care and the early transition to the outpatient setting.’ The HRRP was built on this premise that hospitals’ scope responsibility should include post-discharge care coordination, although essentially no empirical evidence supports the use of a thirty-day readmission interval for assessing hospital-modifiable quality in all settings and clinical domains. Despite substantial economic impact on facilities, and potential impact on the care that patients receive, it is not clear whether hospitals can practicably affect care for such a long period after discharge.”

So here are the two key sets of findings. Per the first set of findings, the researchers found that the intracluster correlation coefficient (ICC), which represents the proportion of risk explained by hospitals (between-hospital variation) compared to the total risk in the population (all variation), “for all three specific medical conditions dropped rapidly from 2.7 percent (acute myocardial infarction), 1.6 percent (heart failure), and 3.2 percent (pneumonia) on the first day after discharge, to less than 1.0 percent (all three cohorts) by day four, reaching a minimum of 0.8 percent or less at seven days after discharge. Across all three of these measures,” the researchers write, “most of the hospital quality signal dissipated by the seventh day after discharge—for example, the ICC decreased between the first day and the seventh day by 78 percent, 48 percent, and 76 percent among patients with acute myocardial infarction, heart failure, and pneumonia, respectively.”

In layperson speak, that means simply this: though hospitals are being made responsible under the HRRP for readmissions to inpatient care through 30 days, the fact of this is that it is really only in the first seven days that such readmissions are effectively meaningful.

On the other hand, the researchers note that “Patients who resided in ZIP codes in the lowest household income quartile had higher thirty-day readmissions risk… Similarly, patients residing in the smallest rural communities, compared to the largest urban communities, experienced at least 41 percent greater thirty-day readmission risk.”