Readmission Rates Declined After HRRP, Especially for Low-Performing Hospitals

After the passage of the Affordable Care Act (ACA) in 2010, hospital readmission rates decreased nationwide, most dramatically for the lowest-performing hospitals, according to an analysis of readmissions data published in the Annals of Internal Medicine. The study indicates that the Medicare Hospital Readmission Reduction Program (HRRP) implemented as part of the sweeping healthcare law has been successful.

The HRRP allows CMS to financially penalize hospitals for poor performance based on rates of readmission within 30 days of discharge after hospitalization for acute myocardial infarction, congestive heart failure, and pneumonia. Before the ACA’s passage, only the highest-performing hospitals saw a minor downward trend in readmission rates, while the rates among the average, low, and lowest-performing hospitals remained stable or increased slightly.

Researchers defined the intervention point as March 2010, when the ACA was passed and hospitals learned that they would eventually be penalized for high readmission rates, although the penalties had not yet taken effect. Overall, risk-standardized readmissions had been increasing by around 0.5 per 10,000 discharges per year before the law’s passage, and decreased by 76.6 per 10,000 discharges per year after the law was passed. After stratifying the hospitals into high-, average-, low-, and lowest-performing groups based on the size of their HRRP penalties, the researchers found some interesting disparities among these groups.

“Our main findings suggest that passage of the law was followed by widespread reductions in readmission rates, even with control for prelaw trends, and that this effect was most concentrated among the lowest-performing hospitals,” the authors wrote.

The highest-performing hospitals saw a decrease in readmissions of 69.0 per 10,000 discharges per year, but the lowest-performing hospitals had their readmissions rates decrease by 92.4 per 10,000 discharges. After controlling for prelaw trends, the researchers determined that 95.1 readmissions per 10,000 discharges were averted among the lowest-performing hospitals, while just 67.6 readmissions were averted for the high-performing hospitals.

The study authors wrote that the accelerated drop of readmissions rates for lower-performing hospitals could partially be due to these hospitals having more room for improvement, but the “results present strong evidence that passage of the law caused this change in hospital performance patterns.”

Consistent with other research, the study found that the hospitals with the lowest performance served a greater percentage of black patients, female patients, and Medicare-Medicaid-eligible patients than the high-performing hospitals. Previous studies have raised concerns that these safety net hospitals may be penalized unfairly by the HRRP, as their readmission rates improved less than those of comparable hospitals with similar initial readmission rates. However, the Annals of Internal Medicine study conducted a sensitivity analysis to adjust for patient and hospital characteristics, which did not alter its findings.

“Distinguishing among the reasons that lower-performing hospitals achieved more accelerated improvement will be essential to sustaining improvement and reducing disparities in care between hospitals,” the study concluded.