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CMS Incentivizes Bad Health Care - Hospital Readmissions Reduction Program Associated With Higher Mortality
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From Jules: So much for our Health System, It Puts Our Patients & HIV+ at RISK, Attempts by CMS, feds & states to reduce healthcare costs like the "Pay for Performance" or value-based care federal programs supported by local NYS and national insurers PUT PATIENTS AT RISK, so does HIV healthcare infrastructure as reimbursement reductions have forced HIV clinics & major hospitals to REDUCE time spent in visit with doctor & patient putting our HIV+ who are aging at greater risk because now with aging they need more time, more attention in visits & more collaboration between specialist & doctor but they are getting LESS.
This is one of the Aging & HIV Healthcare Ryan White Care Act Infrastructure Problems.
DECEMBER 26, 2018
By IDSE News Staff
https://www.idse.net/Hospital-Acquired-Infection/Article/12-18/Hospital-Readmissions-Reduction-Program-Associated-With-Higher-Mortality/53682?sub=747A6C7B288AFFC0C1D9FA943B86C84C2D7CA90D99A344811EAE303450CD21&enl=true
Imposing financial penalties to reduce hospital readmissions appears to be fairly costly for patients. A new study found an increase in post-discharge deaths among patients with pneumonia, myocardial infarction (MI) and heart failure (HF) (JAMA 2018 Dec 25. [Epub ahead of print]).
The Hospital Readmissions Reduction Program (HRRP) was established in 2010 as part of the Affordable Care Act and required that beginning in 2012, the Centers for Medicare & Medicaid Services (CMS) impose financial penalties on hospitals with higher-than-expected 30-day readmission rates for patients initially hospitalized for three conditions: HF, MI and pneumonia.
"Policymakers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable," said the study's first author Rishi Wadhera, MD, MPP, MPhil, an investigator in the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center (BIDMC) and a cardiology fellow in the Cardiovascular Division at Brigham and Women's Hospital Heart & Vascular Center, both in Boston.
As a result, many hospitals made changes to reduce readmissions, and subsequently 30-day readmission rates among Medicare beneficiaries decreased for all three conditions. But as the researchers pointed out, policymakers and physicians have raised concerns that the HRRP may also have had unintended consequences that adversely affected patient care-potentially leading to increased mortality.
"Some policymakers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care," said Dr. Wadhera, who is also a clinical fellow in medicine at Harvard Medical School in Boston. "But the financial penalties imposed by HRRP may have also inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives."
The research team evaluated trends in mortality among Medicare patients who were hospitalized for HF, MI or pneumonia before the start of the HRRP and then determined whether there was a significant change in mortality after the HRRP was announced in 2010, and then again after the policy was implemented in 2012.The researchers examined more than 8 million Medicare fee-for-service hospitalizations from 2005 to 2015. "Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented," said co-corresponding author Changyu Shen, PhD, a senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC and an associate professor of medicine at Harvard Medical School.
The team also found mortality rates among patients with pneumonia were actually stable before the HRRP, but then began increasing after the program. "Whether the HRRP is responsible for this increase in mortality requires further research; but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement," Dr. Shen said.
According to Robert Yeh, MD, MSc, the director of the Smith Center for Outcomes Research in Cardiology at BIDMC and an associate professor of medicine at Harvard Medical School, the implications of this policy are significant for hospitals across the country. "Nearly $2 billion in financial penalties have been imposed on hospitals by the HRRP since 2012, and this national policy has affected nearly all hospitals in a significant way."
Original Investigation
December 25, 2018
Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia
JAMA. 2018
Key Points
Question Was the announcement and implementation of the Hospital Readmissions Reduction Program (HRRP) associated with an increase in patient-level mortality?
Findings In this retrospective cohort study that included approximately 8 million Medicare beneficiary fee-for-service hospitalizations from 2005 to 2015, implementation of the HRRP was associated with a significant increase in trends in 30-day postdischarge mortality among beneficiaries hospitalized for heart failure and pneumonia, but not for acute myocardial infarction.
Meaning There was a statistically significant association with implementation of the HRRP and increased post-discharge mortality for patients hospitalized for heart failure and pneumonia, but whether this finding is a result of the policy requires further research.
Abstract
Importance The Hospital Readmissions Reduction Program (HRRP) has been associated with a reduction in readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. It is unclear whether the HRRP has been associated with change in patient mortality.
Objective To determine whether the HRRP was associated with a change in patient mortality.
Design, Setting, and Participants Retrospective cohort study of hospitalizations for HF, AMI, and pneumonia among Medicare fee-for-service beneficiaries aged at least 65 years across 4 periods from April 1, 2005, to March 31, 2015. Period 1 and period 2 occurred before the HRRP to establish baseline trends (April 2005-September 2007 and October 2007-March 2010). Period 3 and period 4 were after HRRP announcement (April 2010 to September 2012) and HRRP implementation (October 2012 to March 2015).
Exposures Announcement and implementation of the HRRP.
Main Outcomes and Measures Inverse probabilityÐweighted mortality within 30 days of discharge following hospitalization for HF, AMI, and pneumonia, and stratified by whether there was an associated readmission. An additional end point was mortality within 45 days of initial hospital admission for target conditions.
Results The study cohort included 8.3 million hospitalizations for HF, AMI, and pneumonia, among which 7.9 million (mean age, 79.6 [8.7] years; 53.4% women) were alive at discharge. There were 3.2 million hospitalizations for HF, 1.8 million for AMI, and 3.0 million for pneumonia. There were 270 517 deaths within 30 days of discharge for HF, 128 088 for AMI, and 246 154 for pneumonia. Among patients with HF, 30-day postdischarge mortality increased before the announcement of the HRRP (0.27% increase from period 1 to period 2). Compared with this baseline trend, HRRP announcement (0.49% increase from period 2 to period 3; difference in change, 0.22%, P = .01) and implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%, P = .001) were significantly associated with an increase in postdischarge mortality. Among patients with AMI, HRRP announcement was associated with a decline in postdischarge mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, -0.26%; P = .01) and did not significantly change after HRRP implementation. Among patients with pneumonia, postdischarge mortality was stable before HRRP (0.04% increase from period 1 to period 2), but significantly increased after HRRP announcement (0.26% post-HRRP announcement increase; difference in change, 0.22%, P = .01) and implementation (0.44% post-HPPR implementation increase; difference in change, 0.40%, P < .001). The overall increase in mortality among patients with HF and pneumonia was mainly related to outcomes among patients who were not readmitted but died within 30 days of discharge. For all 3 conditions, HRRP implementation was not significantly associated with an increase in mortality within 45 days of admission, relative to pre-HRRP trends.
Conclusions and Relevance Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI. Given the study design and the lack of significant association of the HRRP with mortality within 45 days of admission, further research is needed to understand whether the increase in 30-day postdischarge mortality is a result of the policy.
Introduction
The Hospital Readmissions Reduction Program (HRRP) was established under the Affordable Care Act (ACA) in 2010 and required that the Centers for Medicare & Medicaid Services (CMS) impose financial penalties on hospitals with higher-than-expected 30-day readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia, beginning in 2012.1 After the announcement of the HRRP, readmission rates among Medicare beneficiaries declined for target conditions nationwide.2,3 Recently, however, policy makers and physicians have raised concern that the HRRP may have also had unintended consequences that adversely affected patient care, potentially leading to increased mortality.4,5 For instance, the financial penalties imposed by the HRRP may have inadvertently pushed some physicians to avoid indicated readmissions, potentially diverted hospital resources and efforts away from other quality improvement initiatives, or worsened quality of care at resource-poor hospitals that are often penalized by the program. However, it is also possible that the same mechanisms by which some hospitals have reduced readmissions, such as improved coordination and transitions of care, resulted in reductions in mortality.
Understanding whether the HRRP has been associated with changes in mortality at the patient level is important as policy makers evaluate this program, particularly given the ongoing expansion of the HRRP to include other conditions6 and the almost $2 billion in financial penalties that have been imposed on hospitals since 2012.7 This study aims to answer 3 questions. First, compared with past trends, was the announcement or implementation of the HRRP associated with a change in mortality within 30 days of discharge following hospitalization for heart failure, acute myocardial infarction, or pneumonia? Second, was the HRRP associated with a change in the distribution of patients who experienced death and no readmission, readmission and no death, readmission and death, or no death and no readmission during the 30 days after discharge? Third, was the HRRP associated with a change in mortality within 45 days of hospital admission for target conditions?
Discussion
Overall, the announcement and implementation of the HRRP was associated with a significant increase in mortality within 30 days of discharge among Medicare beneficiaries hospitalized for heart failure and pneumonia, but not for acute myocardial infarction. Although 30-day postdischarge mortality for heart failure was increasing before the HRRP, this increase accelerated after the announcement and implementation of the program. In addition, postdischarge mortality for pneumonia was stable before the HRRP, but increased after announcement and implementation of the program. The increase in mortality for heart failure and pneumonia were driven mainly by patients who were not readmitted within 30 days of discharge.
Postdischarge mortality was first evaluated because this is the period when many potential changes in care incentivized by the HRRP, intended to lower readmissions, could manifest in terms of mortality.17 In addition, mortality within 45 days of initial admission was also evaluated, because efforts to reduce readmissions could potentially encompass care during the index hospitalization and might influence discharge timing and location of death. Although announcement of the HRRP was associated with a significant increase in mortality for patients with heart failure using this alternate end point, no association was observed between HRRP implementation and increased mortality for all conditions. The difference between findings for postdischarge and postadmission mortality could potentially be explained by in-hospital deaths, which were steadily declining for target conditions in the decade before the announcement and implementation of the HRRP.25,26 The postadmission mortality measure included both in-hospital and postdischarge deaths; thus secular declines in in-hospital deaths may have counterbalanced the increase in postdischarge mortality observed after the announcement and implementation of the HRRP. Hospitals may have also changed practices so that high-risk patients, over time, were discharged earlier, leading to a shift of some deaths from the inpatient to the outpatient setting that was unrelated to the HRRP. Such shifts, however, would need to have accelerated at the time of the announcement and implementation of the HRRP to explain the concomitant increase in postdischarge mortality.
Most concerning, however, is the possibility that the relationship between the HRRP and postdischarge mortality for heart failure and pneumonia is causal, indicating that the HRRP led to changes in quality of care that adversely affected patients. Financial incentives aimed at reducing readmissions were up to 10- to 15-fold greater under the HRRP than incentives to improve mortality through pay-for-performance programs, and some hospitals may have focused more resources and efforts on reducing or avoiding readmissions than on prioritizing survival. Studies have found little evidence that standard measures of care quality for acute myocardial infarction and heart failure are correlated with readmission rates,27,28 suggesting that as hospitals face choices about which quality improvement efforts to prioritize, readmissions could be at odds with other goals. Safety net hospitals and hospitals serving a high proportion of socioeconomically disadvantaged patients were more likely to receive financial penalties under the HRRP, potentially impeding their ability to invest limited resources toward quality improvement efforts to better outcomes.29-32 In addition, the HRRP may have pushed some physicians and institutions to increasingly treat patients who would have benefited from inpatient care in emergency departments or observation units, which could be consistent with the finding that increases in postdischarge mortality for heart failure and pneumonia were entirely driven by patients who were not readmitted within 30 days of discharge. This is also in line with analyses that have shown that following the HRRP, inpatient readmissions declined while emergency department and observation unit stays increased among patients returning to a hospital within 30 days for target conditions.33
Alternatively, factors unrelated to the HRRP could potentially explain the observed increases in postdischarge mortality. Greater use of hospice care at the end of life might shift deaths that previously occurred within a hospital to the postdischarge setting over time.21,22 However, increases in aggregate death and death without readmission were similar even after excluding patients receiving hospice care, indicating that these trends were not explained by greater use of hospice after hospital discharge. Increases in mortality after the announcement and implementation of the HRRP could potentially reflect greater use of do-not-resuscitate orders among hospitalized beneficiaries. In a sample of hospitals in California, for example, the proportion of do-not-resuscitate orders among patients hospitalized for heart failure increased over time.34 If these patterns were similar on a national scale, trends in mortality might simply reflect greater focus on and attention to goals of care among hospitalized patients or on patients with advanced heart failure increasingly declining life-prolonging care after discharge. It is also possible that the overall increase in postdischarge mortality for heart failure reflects increasing severity of illness among admitted patients that is not captured in claims data. In incentivizing hospitals to not admit patients, the HRRP might have been associated with a change in patients who reached the threshold of admission, resulting in the healthiest portion of these encounters to be managed in the emergency department and observation units and leaving an increasingly higher risk population to be managed in the inpatient setting. Such a shift, if uncaptured in claims, could have led to an increase in mortality after hospitalization for heart failure. In contrast, for pneumonia, recent evidence suggests that shifts in coding practice may have resulted in a healthier cohort of patients over time, because hospitals have increasingly recoded severely ill patients with pneumonia to sepsis or respiratory failure with pneumonia.35,36 Such shifts in coding make the observed increase in postdischarge mortality among patients with pneumonia less likely to be due to increases in unmeasured disease severity.
The current study builds upon a body of evidence regarding the intended and potential unintended consequences of the HRRP amid recent calls to restructure and improve the program.5,30,37 Previous work has shown mixed findings regarding the relationship between the HRRP and mortality. A report by the Medicare Payment Advisory Commission demonstrated declines in risk-adjusted mortality since 2008 for all target conditions,33 which was inconsistent with a number of past analyses that have demonstrated an increase in heart failure and pneumonia mortality rates over the same period.17-19,38 A 2018 study showed no significant association between the HRRP and increased mortality for target conditions.39 A third investigation observed a weakly positive correlation between the HRRP and monthly changes in readmissions and postdischarge mortality at the hospital level for all target conditions.17 Although hospitals that reduce readmissions also appear to reduce mortality, this hospital-level concordance does not reflect the change in readmissions and mortality at the level of the patient population, which is arguably of greater importance to individual patients and to public health. The current analysis is unique in that all Medicare inpatient claims data were used to examine both postadmission and postdischarge mortality at the patient level, stratified outcomes were evaluated to provide mechanistic insights, and an IPW approach was used to compare outcomes among similar patient populations in exposure periods before and after the announcement and implementation of the HRRP.
Limitations
This study has several limitations. First, given the observational design, we are unable to make inferences about causality or the mechanisms that explain the increase in mortality associated with the HRRP for some target conditions. Nevertheless, we attempted to account for secular trends in mortality using baseline years during which the HRRP was not in effect, making it unlikely that observed associations between the HRRP and mortality were due to preexisting trends alone. Second, patient severity of illness may have differed in ways that were not captured by claims data. But, to minimize confounding, we used inverse probability weighting, an approach that is less susceptible to biased estimates of the HRRP's association with mortality due to imbalances in covariates over time. Third, recent studies have demonstrated up-coding associated with the HRRP, although such changes would have attenuated the observed relationship between the HRRP and increased mortality.40
Conclusions
Among Medicare beneficiaries, announcement and implementation of the HRRP were significantly associated with an increase in 30-day postdischarge mortality following hospitalization for heart failure and pneumonia, but not for acute myocardial infection. Given the study design and the lack of significant association of the HRRP implementation with mortality within 45 days of hospital admission, further research is needed to understand whether the increase in 30-day postdischarge mortality is a result of the HRRP.
Results
There were 8 326 688 Medicare fee-for-service hospitalizations for heart failure, acute myocardial infarction, and pneumonia from April 1, 2005, to March 31, 2015, among which 7 948 937 patients were alive at hospital discharge. The mean (SD) age of the study population was 79.6 (8.7) years, 4 246 454 participants (53.4%) were women, 6 802 296 (85.6%) were white, and 738 198 (9.3%) were black. There were 3.2 million hospitalizations for heart failure, 1.8 million for acute myocardial infarction, and 3.0 million for pneumonia and, overall, there were 270 517 deaths from heart failure, 128 088 deaths from acute myocardial infarction, and 246 154 deaths from pneumonia within 30 days of discharge. Baseline patient demographics were similar among the 4 study periods; comorbidities are shown in Table 1 for patients alive at discharge. Observed trends in 30-day postdischarge and 45-day postadmission outcomes for target conditions are shown in Figure 2 and eTables 1 and 2 in the Supplement.
HRRP and 30-Day Postdischarge Mortality
Among patients with heart failure, IPW-adjusted postdischarge mortality (Figure 3A and eTable 3 in the Supplement) increased before the announcement or implementation of the HRRP (0.27% increase from period 1 to period 2; Table 2). Relative to this baseline trend, the announcement of the HRRP was significantly associated with an increase in postdischarge mortality (0.49% increase from period 2 to period 3; 0.22% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). An analysis stratified by whether there was an associated readmission showed that this change was entirely driven by a significant increase in mortality without readmission (0.27% increase from period 1 to period 2 vs 0.53% increase from period 2 to period 3; 0.26% difference between the change from period 1 to period 2 and period 2 to period 3; P < .001). In addition, HRRP implementation was significantly associated with an increase in postdischarge mortality overall relative to baseline trends (0.52% increase from period 3 to period 4; 0.25% difference between the change from period 1 to period 2 and period 3 to period 4; P = .001), which was also explained by an increase in death without readmission.
In contrast, among patients with acute myocardial infarction (Figure 3B), HRRP announcement was significantly associated with a decline in postdischarge mortality (Table 2; 0.18% increase from period 1 to period 2 vs 0.08% decrease from period 2 to period 3; -0.26% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). Compared with baseline trends, HRRP implementation was not associated with a significant change in mortality (0.15% increase from period 3 to period 4; -0.03% difference between the change from period 1 to period 2 and period 3 to period 4; P = .69).
Postdischarge mortality among patients with pneumonia (Figure 3C) was relatively stable before the HRRP (0.04% increase from period 1 to period 2), but increased significantly after announcement of the HRRP (Table 2; 0.26% increase from period 2 to period 3; 0.22% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). This overall change was driven by an increase in patients who were not readmitted but died within 30 days of discharge (0.09% increase from period 1 to period 2 vs 0.32% increase from period 2 to period 3; 0.23% difference between the change from period 1 to period 2 and period 2 to period 3; P = .003). In addition, compared with baseline trends, HRRP implementation was also significantly associated with an increase in mortality overall (0.44% increase from period 3 to period 4; 0.40% difference between the change from period 1 to period 2 and period 3 to period 4; P < .001) and among stratified mortality outcomes of death and no readmission (0.09% from period 1 to period 2 vs 0.38% from period 3 to period 4; 0.30% difference between the change from period 1 to period 2 and period 3 to period 4; P < .001) and readmission and death (0.05% decrease from period 1 to period 2 vs 0.05% increase from period 3 to period 4; 0.11% difference between the change from period 1 to period 2 and period 3 to period 4; P = .003).
All P values less than .05 for the 18 comparisons involving 3 end points (total mortality, mortality without readmission, and mortality with readmission), 2 differences in change (post-HRRP announcement trends and post-HRRP implementation trends compared with pre-HRRP trends) and 3 conditions (heart failure, acute myocardial infarction, and pneumonia) were also significant at the FDR level of 0.05 (Table 2).
Other 30-Day Postdischarge Outcomes
Inverse probability-weighted readmissions without death within 30 days declined significantly following the announcement and implementation of the HRRP compared with the years preceding the HRRP for all 3 target conditions (Table 2). Trends across study periods in rates of patients who were not readmitted and were alive within 30 days of discharge are also shown in Table 2 and eTable 3 in the Supplement.
HRRP and 45-Day Postadmission Mortality
Trends in IPW-adjusted postadmission mortality rates are shown in Figure 4 and eTable 4 in the Supplement. Among patients hospitalized for heart failure, postadmission mortality rates steadily increased before the announcement of the HRRP (Table 2; 0.15% increase from period 1 to period 2). Compared with this baseline trend, the HRRP announcement was significantly associated with an increase in mortality (0.42% increase from period 2 to period 3; 0.27% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). However, mortality did not significantly change after HRRP implementation (0.32% increase from period 3 to period 4; 0.17% difference between the change from period 1 to period 2 and period 3 to period 4; P = .06).
Postadmission mortality declined among patients hospitalized for acute myocardial infarction before the announcement of the HRRP (0.24% decline from period 1 to period 2), a trend that did not significantly change after the HRRP announcement (0.35% decline from period 2 to period 3; -0.12% difference between the change from period 1 to period 2 and period 2 to period 3; P = .39). Following the HRRP implementation, postadmission mortality continued to decline (0.44% from period 3 to period 4), but did not significantly differ from baseline trends (-0.21% difference between the change from period 1 to period 2 and period 3 to period 4: P = .06).
Among patients hospitalized for pneumonia, postadmission mortality was relatively stable before the HRRP (0.05% increase from period 1 to period 2), and did not significantly change after the HRRP announcement (0.15% decline from period 2 to period 3; -0.20% difference between the change from period 1 to period 2 and period 2 to period 3; P = .07) and implementation (0.14% increase from period 3 to period 4; 0.09% difference between the change from period 1 to period 2 and period 3 to period 4; P = .30).
Additional Analyses
As a sensitivity analysis, we excluded patients receiving hospice care and observed patterns in postdischarge mortality that paralleled our primary analysis (eTable 5 in the Supplement). After excluding patients receiving hospice care, postdischarge mortality among patients hospitalized for heart failure and pneumonia were declining before the announcement and implementation of the HRRP, but significantly increased after the announcement and implementation due to an increase in mortality without readmission (eTable 6 in the Supplement). Trends in hospice deaths within 30 days of discharge by condition are shown in eTables 7 and 8 in the Supplement. Trends in postdischarge mortality also remained similar when the analysis was restricted to the first hospitalization for each patient in each period (eTables 9 and 10 in the Supplement) or included all hospitalizations for each patient (eTables 11 and 12 in the Supplement). In addition, findings were consistent using the outcome regression-based approach (eTables 13 and 14 in the Supplement).
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