Medicare Readmission Program Helped Narrow Disparities but Gaps Remain, Study Says

Black—white disparities in hospital readmission rates in the United States narrowed after the introduction of the Hospital Readmissions Reduction Program (HRRP), but hospitals that serve a large number of minority patients continue to disproportionately receive penalties for their readmission rates, a study published in Health Affairs said Monday.

The HRRP was established by CMS as part of the Affordable Care Act. Before the HRRP, there was evidence that black patients had, on average, 20% higher readmission rates than white patients, and that hospitals serving a higher proportion of black patients had higher readmission rates than other hospitals—even after taking into account patient complexity.

Previous evidence suggested that the HRRP may have helped lower readmission rates for all Medicare patients over time, but its impact on minority populations and the hospitals that serve them was unknown.

In this study, researchers from the Harvard T.H. Chan School of Public Health compared trends in 30-day readmission rates among black and white patients and among minority-serving and other hospitals from 2007 to 2014. Data came from 2960 hospitals, of which 283 were identified as minority-serving. They analyzed national Medicare data from 6.3 million hospital admissions for patients with acute myocardial infarction, congestive heart failure, and pneumonia, the 3 conditions targeted by the HRRP, seeking to understand if:

• the introduction of the HRRP led to meaningful changes in hospital readmission rates for black patients relative to white patients
• the gap in readmission rates between minority-serving and other hospitals narrowed, widened, or stayed the same
• minority-serving hospitals continued to receive HRRP penalties disproportionately, or if their penalties declined over time relative to those of other hospitals.

The researchers found that, prior to the HRRP (January 2007-March 2010), readmission rates were relatively flat or slightly increasing for both white and black patients. During the HRRP penalty-free implementation phase (April 2010-September 2012), readmission rates improved both for blacks and whites, falling on average 0.45% per quarter for black patients, and a bit slower, 0.36% per quarter, for white patients.

Of the 6.3 million hospital admissions, 89.7% were for white patients and 10.3% were for black patients. In the first study year (2007), compared with white patients, black patients were younger (77.1 vs 79.6 years; P <.001) and more likely to be female (59.8% vs 53.5%; P <.001) and to have comorbidities, including hypertension, diabetes, renal failure, and obesity. White patients were more likely to have chronic obstructive pulmonary disease and depression. Researchers found similar patterns in 2014 and across all other years of data.

In the period after HRRP penalties were introduced (October 2012-December 2014), improvements in 30-day readmission rates slowed.

Overall, black patients' 30-day readmission rates fell from a high of 24.5% in 2010 to 18.9% in 2014, whereas white patients' rates fell from a high of 22.5% to 17.7%.

Even though minority-serving hospitals made more improvements than other hospitals, they were still more likely to be penalized because the HRRP program rewards hospitals based on their ranking relative to each other and not based on their own improvement over time, according to the study.

The results suggest that more work needs to be done to ensure that pay-for-performance programs promote greater equity in care.

The authors speculated that minority-serving hospitals' lack of resources may hamper their efforts to reduce readmissions.

"To better incentivize and reward all hospitals, including those at the bottom, policy makers should consider changes to how penalties are determined in the HRRP," said lead author José Figueroa, MD, MPH, Burke Fellow at the Harvard Global Health Institute and a physician at Brigham and Women's Hospital, in a statement.

It remains to be seen whether policy changes will narrow these gaps and reduce the disproportionately high penalties that minority-serving hospitals face, the authors said.

Reference

Figueroa JF, Zheng J, Orav EJ, Epstein AM, et al. Medicare program associated with narrowing hospital readmission disparities between black and white patients [published online April 2, 2018]. Health Aff (Millwood). doi: 10.1377/hlthaff.2017.1034.