For Patients With Heart Failure, Healthcare Reform Brings Change and Unintended Consequences

Heart failure patients are among the most medically challenged—beyond being unable to pump enough blood to carry oxygen to meet the body’s needs, they typically have other problems like hypertension or diabetes. For years, there was little incentive to keep these patients out of the hospital, because each time they were admitted, the hospital got paid.

Healthcare reform pledged to do better for this group, creating the incentives and team-based approaches these fragile patients need. In some cases, this has happened, but there have also been unintended consequences, according to a panel appearing Sunday at the 67th Scientific Session of the American College of Cardiology (ACC), being held in Orlando, Florida.

Thirty-day readmissions have declined, even though CMS recently hit 2600 hospitals with penalties for failing to hit targets. However, panelist Gregg C. Fonarow, MD, FACC, director of the Ahmanson-UCLA Cardiomyopathy Center, said recent reports suggest the numbers may not be what they seem, as some hospitals may be treating patients in the emergency department (ED) under “observation” status to avoid recording readmissions. Worse still, Fonarow was co-author on a JAMA Cardiology paper that found the decrease in 30-day readmissions under the Hospital Readmissions Reductions Program (HRRP) has been accompanied by an increase in 30-day risk-adjusted mortality.¹

Larry Allen, MD, MHS, FACC, noted that during the runup to the Affordable Care Act (ACA), CMS let hospitals know where they stood with 30-day readmissions, first privately, and then publicly, so institutions and physicians could prepare for the day when poor performance would hurt the bottom line. Allen is a specialist in advanced heart failure and transplant cardiology at the University of Colorado.

The HRRP took effect in 2010, and by 2018, CMS penalties reached $564 million; 30-day readmission for heart failure got the earliest scrutiny and is the focal point for value-based contracting. The program has legions of critics, Allen said. Criticism may be warranted, but that doesn’t mean metrics don’t matter.

“Start with the end in mind,” he said. “We should not argue whether to measure quality and value. We should argue how to measure quality and value.”

And that, other speakers said, has been the rub. When a hospital’s mortality rate is overlooked in favor of readmission rates, something’s wrong, they said. Allen said while heart failure readmissions add significantly to costs and are an important indicator of other problems, it doesn’t make sense that their penalty from CMS is 3%, while mortality is 0.5%.

Yet, HRRP has forced different parts of the hospital to work together to help patients. “The only thing worse than paying attention to 30-day readmissions would be not to,” he said.

Part of the challenge is that readmissions is just one measure among so many that physicians and hospitals are trying to absorb. Panelist Srinath Adusumalli, MD, a fellow in the Division of Cardiovascular Medicine at the University of Pennsylvania, offered an update on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), explaining that only about 15% of physicians qualify for an advanced alternative payment model (APM). It’s hard to keep up with the evolving requirements: this time a year ago, ACC members were getting ready for a new mandatory cardiac bundled payment program, which has since been canceled.

Adusumalli noted that the new voluntary advanced APM, Bundled Payments for Care Improvement, has an initial filing deadline of Monday. For all the criticism, he said, “It’s likely that MACRA is here to stay.”

Shashank S. Sinha, MD, MSc, an advanced heart failure and transplant fellow at the University of Michigan, presented a study of hospital accountable care organization (ACO) participation and episode spending for congestive heart failure (CHF) admission. The thinking going in was that being in an ACO would have greater effects more than 90 days after admission. The study captured 260,420 Medicare beneficiaries in 3208 hospitals, including 412 in ACOs.

They tracked spending by year from 2012 to 2014, as well as beneficiaries never in an ACO and found that savings of $889 per episode for CHF and acute myocardial infarction. The spending was driven by lower payments late in the episode, Sinha said. Early adopters—those who signed on to be ACOs back in 2012—did the best.

Fonarow did not have positive reviews about ACOs. “For the most part, with ACOs, there’s no evidence of improvement in clinical outcomes,” he said. “And they are creating a very heavy administrative burden for clinicians.”

He said there are often complaints that things for heart failure patients would be better “if only we had a different system,” with different incentives. Certainly, he said, there have been programs with dedicated teams including advanced nurse practitioners and comprehensive care, that drove substantial reductions in hospitalization.

Those efforts showed that systems lose money not applying such programs.

As one speaker noted during the question and answer session, even if the uptick in hospital mortality was not due to the HRRP, isn’t it important to find out what is the cause?

Reference

Gupta A, Allen LA, Bhatt DL, et al. Association of the Hospital Readmissions Reductions Program implementation with readmission and mortality outcomes in heart failure. JAMA Cardiol. 2018;3(1):44-53. doi:10.1001/jamacardio.2017.4265