News: Financial penalties for hospital readmissions linked to higher mortality
Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, according to a recent study by the Journal of the American Medical Association (JAMA).
In the study, researchers at Beth Israel Deaconess Medical Center examined the unintended consequences of the Hospital Readmissions Reduction Program (HRRP), HealthLeaders Media reported.
Under the HRRP, hospitals have faced financial penalties for higher-than-expected 30-day readmissions for heart failure, pneumonia, and heart attack. Nearly $2 billion in penalties have been imposed on hospitals by the HRRP since 2012.
“Policy makers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable,” study author Rishi Wadhera, MD, said in comments accompanying the study.
To a certain extent, HRRP worked. Hospitals made changes to avoid readmissions rates among Medicare beneficiaries and readmissions rates for those three conditions fell. However, a growing chorus of researchers and physicians have raised concerns that the drop in readmissions has led to increased mortality, according to HealthLeaders Media.
“Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care,” Wadhera said. “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.”
The researchers examined more than eight million Medicare fee-for-service hospitalizations from 2005 to 2015. They evaluated mortality among Medicare patients who were hospitalized for heart failure, a heart attack, or pneumonia before the establishment of HRRP in 2012.
Then, they compared those trends to determine if there was a significant change in mortality after the HRRP was announced in 2010, and after the policy was implemented in 2012.
“Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented,” said co-corresponding author Changyu Shen, PhD, senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC.
The team also found mortality rates among patients with pneumonia were stable prior to HRRP, but began increasing after the HRRP. “Whether the HRRP is responsible for this increase in mortality requires further research, but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement,” Shen said.
Readmissions has become a controversial topic among physicians and researchers, with some studies indicating that it leads to a rise in mortality, and other studies indicating that HRRP has improved care delivery, HealthLeaders Media reported. In fact, a study published last fall in JAMA suggested that financial penalties for readmissions did not seem to have affected mortality rates either in-hospital or after discharge at all.
The primary implication of the new research is that health systems and hospitals need to make broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.