HRRP May Have Done More Harm for Patients With Heart Failure and Pneumonia

Medicare beneficiaries who were hospitalized for heart failure and pneumonia had a higher 30-day postdischarge mortality after the implementation of the Hospital Readmission Reduction Program, according to a study in JAMA.

The HRRP is a value-based purchasing program established in 2010 as part of the Affordable Care Act that pays hospitals based on their readmissions. Hospitals with excess readmissions in 3 target conditions—heart failure, acute myocardial infarction, and pneumonia—receive a reduced payment.

“After the announcement of the HRRP, readmission rates among Medicare beneficiaries declined for target conditions nationwide,” the authors wrote. “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.”

The researchers used Medicare Provider Analysis and Review files to identify relevant admissions and discharges from April 1, 2005, to March 31, 2015. They used 2 study periods before HRRP to establish baseline trends (periods 1 and 2) and 2 periods after the HRRP was established (period 3 occurred right after the announcement of the HRRP and period 4 took place when the HRRP was implemented).

There were a total of 7,948,937 Medicare patients discharged after being hospitalized for heart failure, acute myocardial infarction, and pneumonia during the time period of the study. The mean age was 79.6 years, 53.4% were women, and 85.6% were white.

“Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care,” the study’s first author Rishi Wadhera, MD, MPP, MPhil, an investigator in the Smith Center for Outcomes Research in Cardiology at BIDMC and a Cardiology Fellow in the Cardiovascular Division at Brigham and Women’s Hospital Heart & Vascular Center, said in a statement. “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.”

This is the second study in a year to ask whether the HRRP is having unintended consequences for patients with heart failure. A study involving 115,000 patients and only those with heart failure appeared in the January 2018 issue of JAMA Cardiology and reached the same finding of increased mortality. The findings were presented in March at the American College of Cardiology.

This new study found that just the announcement of the HRRP resulted in an associated increase in postdischarge mortality. From period 2 to period 3 there was a 0.49% increase in postdischarge mortality. From period 3 to period 4 (HRRP announcement to actual implementation) there was a 0.52% increase in postdischarge mortality overall relative to baseline.

The changes varied based on the condition. HRRP implementation was not associated with a significant change in postdischarge mortality for patients with acute myocardial infarction. Meanwhile, postdischarge mortality for patients with pneumonia increased significantly (0.26% increase from period 2 to period 3), largely driven by an increase in patients who were not readmitted and 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).

“The implications of our findings are very important,” said cocorresponding author Robert Yeh, MD, MSc, director of the Smith Center for Outcomes Research in Cardiology at BIDMC and associate professor of medicine at Harvard Medical School. “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. This is an example of how we can’t always predict the consequences of applying external incentives to medical care.”

Reference

Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542-2552. doi:10.1001/jama.2018.19232