Study Questions Penalizing, Incentivizing PCPs for Readmission Rates

The Hospital Readmissions Reduction Program from CMS may have successfully reduced readmissions among Medicare beneficiaries, but research has shown that the success has been mixed. JAMA published a study in December 2018 that showed postdischarge mortality increased for beneficiaries hospitalized for heart failure and pneumonia,¹ and a Health Affairs study from April 2018 showed that hospitals that serve a large number of minority patients disproportionately receive penalties for readmission rates.²

Now, new research in Annals of Internal Medicine has taken a look at variation in readmission rates among primary care providers (PCPs).³ The researchers studied Texas Medicare claims from 2008 to 2015 for patients discharged between January 1, 2008, and November 30, 2015 who had a PCP in the year prior. They also only included patients whose PCP had at least 50 admissions during the study period.

“Risk for readmission might be influenced by the physicians providing care,” the authors noted. They added that “whether PCP care influences readmissions is uncertain, although CMS has implemented a policy incentivizing PCPs to reduce readmissions.”

The study included 2 cohorts: 1 to study 30-day readmission rates, and 1 to study whether patients were seen by their PCP within 7 days of discharge. A total of 565,579 patients and 4230 PCPs were included.

Higher adjusted readmission rates were associated with being older, male, ineligible for Medicaid, an emergency or weekend admission, nursing home residence, higher diagnosis-related group weight, and more inpatient or ambulatory care episodes in the past year. However, the authors noted that the associations were mostly of small magnitude.

The average risk-standardized readmission rate for the PCPs was 12.9%, and the researchers found there was little variation—the minimum was 11.2% and the maximum was 15.3%. No PCPs had a rate that was statistically significantly lower than the average, and only 1 PCP had a rate that was statistically significant higher.

Overall, 20.4% of beneficiaries saw their PCP within 7 days of hospital discharge. These patients were more likely to be older, Hispanic, or male; had an emergency admission; had multiple physician visits in the past year; or resided in an area with a higher proportion of adults with a high school education. There was more variation among the rates of PCPs seeing patients within 7 days, with 14% having adjusted follow-up rates significantly above average and 16% having rates significantly below.

According to the researchers, the findings have important implications for health policy, considering the Merit-based Incentive Payment System (MIPS) was launched with an underlying assumption that readmission rates vary by PCP. MIPS uses penalties and incentives to incentivize PCPs to reduce readmissions by changing their practice patterns.

“Our finding of minimal variation in risk for readmission among PCPs calls into question any pay-for-performance program that aims to reduce readmissions and assumes variation by PCP,” the authors wrote.

References

1. 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.

2. Figueroa JF, Zheng J, Orav EJ, Epstein AM, et al. Medicare program associated with narrowing hospital readmission disparities between black and white patients. Health Aff (Millwood). 2018;37(4):654-661. doi: 10.1377/hlthaff.2017.1034.

3. Singh S, Goodwin JS, Zhou J, Kuo Y-F, Nattinger AB. Variation among primary care physicians in 30-day readmissions [published online May 21, 2019]. Ann Intern Med. doi: 10.7326/M18-2526.