Are Improvements Still Needed to the Modified Hospital Readmissions Reduction Program: a Health and Retirement Study (2000–2014)?

Abstract

BACKGROUND:To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients ("peer group hospitals"). Whether the change fully accounts for patients' social and functional risks is unknown. OBJECTIVE: Examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors. DESIGN: Using 2000-2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, latent factors for patient social and functional factors and community factors were identified. We estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: "base" (HRRP model); "patient" (base plus patient factors); "community" (base plus community factors); and "full" (all factors). The proportion of hospitals penalized was calculated by safety net status. PATIENTS: 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations MAIN MEASURES: RSRRs KEY RESULTS: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized. CONCLUSIONS: Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patientlevel risk.

Emergency departments in the United States treating high proportions of patients with ambulatory care sensitive conditions: a retrospective cross-sectional analysis

“…Our analysis also suggested that other safety net definitions may not adequately capture high ACSC hospitals. For instance, although we observed an association between ACSC visits to high ACSC hospitals and to hospitals with the highest quintile of dual-eligible patients, which previous work suggests may serve patients who are particularly vulnerable, [ 23 ] the overall proportion of dual-eligible patients was only weakly correlated with proportion of ACSC visits. Our results also suggest that high ACSC hospitals were less likely to be public hospitals, and more likely to be for-profit hospitals, compared to non-profit hospitals, which may reflect findings from previous studies that geography and market structure may influence service offerings and patient case-mix at hospitals of different ownership [ 32 – 35 ].…”

“…The primary predictor of interest was hospital safety net status. Because of the multiple definitions for safety net status, we used three different definitions: (i) hospitals with the highest quartile of the DSH patient percentage; (ii) public hospitals; and (iii) EDs serving the highest quintile of age-eligible Medicare patients with dual-eligibility for Medicare and Medicaid [ 20 – 23 ].…”

Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives

“…Further, the peer group-based payment adjustment approach was introduced to the HRRP and implemented beginning in 2019. Early evidence shows that peer grouping resulted in relatively lessening the burden of financial penalties serving more socially disadvantaged patients (104)(105)(106)(107). However, the current modification has limitations where it merely reflects on its readmission outcomes and not the social risk factors of its patients, which is the fundamental goal, and it might not be an perfect approach to address health care inequities in the current form (107).…”

Medicare's Hospital Readmission Reduction Program reduced fall‐related health care use: An unexpected benefit?

“…In all, the results suggest that the incorporation of fall injuries into evaluations of national policy might benefit older adult welfare. HRRP has been critiqued for its limited impact on quality, 50 , 51 , 52 , 53 leading to calls for its withdrawal as a quality program. 37 , 48 Yet, a more comprehensive evaluation may offer a different portrait, by revealing effects on clinically and socially relevant outcomes involving fall injuries.…”