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Invited Commentary
Health Policy
May 31, 2019

A Decade Later, Lessons Learned From the Hospital Readmissions Reduction Program

Author Affiliations
  • 1HOK Architects, New York, New York
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Department of Surgery, University of Michigan, Ann Arbor
JAMA Netw Open. 2019;2(5):e194594. doi:10.1001/jamanetworkopen.2019.4594

The Hospital Readmissions Reduction Program (HRRP) was established as part of the Patient Protection and Affordable Care Act in 2010 in response to reports that readmissions were common, costly, and potentially preventable.1 The policy established financial penalties for hospitals with higher-than-expected readmission rates and initially targeted 3 common medical conditions: heart failure, pneumonia, and acute myocardial infarction. The program was later expanded to other conditions, including total knee replacement and total hip replacement. Early reports widely praised the policy for its effect on readmission rates and for serving as a successful pioneer in alternative payment models. The HRRP not only demonstrated significant reductions in readmission rates for the targeted medical conditions but also had a notable spillover effect to nontargeted conditions,2 including surgical procedures.3 However, later reports raised concerns about the unintended consequences of the policy, including increased rates of mortality and abrupt changes in coded severity.4-6 Taken together, there has been growing desire from payers, health care professionals, policy makers, and patients to better understand the true impact of the HRRP, including its most recent iteration, which adds surgical procedures.

Ramaswamy et al7 evaluated the association of HRRP with targeted surgical procedures. They used the Nationwide Readmissions Database and found that targeted surgical procedures (total knee replacement and total hip replacement) experienced lower rates of readmission compared with similar nontargeted surgical procedures. The findings are consistent with hospitals responding to financial incentives and making targeted efforts to improve their quality of care. Advocates of the HRRP will welcome these findings as justification for broadening the current surgical conditions. Those concerned about the policy will rightly point out 2 major limitations of the study by Ramaswamy et al7: (1) the lack of secondary outcomes to identify unintended consequences (eg, use of observations status, evaluation of mortality) and (2) the lack of an equivalent control group (ie, same procedure) that was not exposed to the policy. Nonetheless, the study adds another important layer to our growing understanding of this landmark policy of the Patient Protection and Affordable Care Act.

Now, nearly a decade since the HRRP was established, lessons for future policies to improve quality of care have emerged (Table). First, perhaps the most widely agreed on success of the HRRP is that it had large enough penalties to motivate changes. While the exact mechanism is not entirely known, health systems clearly made significant efforts to reduce readmissions in response to the program. Second, the policy had effects far beyond the initial targeted conditions. Nearly all studies of the program demonstrate that the initial announcement resulted in readmission reductions across nontargeted procedures. Policy makers can take advantage of this phenomenon by strategically focusing on key service lines that would also have spillover effects to the rest of the system. Third, the unintended consequences of any large-scale policy need to be proactively anticipated and mitigated. Doing so will be essential for payers and policy makers to maintain goodwill with clinical professionals and patients. Finally, implementation of large-scale policy interventions should be done so that evaluation can be rigorously performed. Much of the debate about the true impact of the HRRP has been hindered by observational study designs that do not have an appropriate comparison group because the policy was implemented in all eligible hospitals concurrently. Future policy interventions should be implemented in a step-wedge fashion so that secular trends and confounders can be accounted for. Had the HRRP been implemented as a step-wedge study design, it would provide us better data to separate fact from artifact.

Table.  
Lessons Learned From the Hospital Readmissions Reduction Program (HRRP) to Guide Future Policy Design and Evaluation
Lessons Learned From the Hospital Readmissions Reduction Program (HRRP) to Guide Future Policy Design and Evaluation

Debates about the benefits and drawbacks of the HRRP will continue. However, we now have a road map for how we can better design and evaluate future large-scale policy interventions to improve the delivery of health care.

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Article Information

Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.4594

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Ibrahim AM et al. JAMA Network Open.

Corresponding Author: Andrew M. Ibrahim, MD, MSc, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Ave, Bldg 10, Ste G016, Ann Arbor, MI 48109-2800 (iandrew@umich.edu).

Conflict of Interest Disclosures: Dr Ibrahim reported receiving personal fees as the Chief Medical Officer of HOK Architects, a global design and architecture firm. Dr Dimick reported owning equity in ArborMetrix, a health care analytics company.

References
1.
Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program.  N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563PubMedGoogle ScholarCrossref
2.
Zuckerman  RB, Sheingold  SH, Orav  EJ, Ruhter  J, Epstein  AM.  Readmissions, observation, and the Hospital Readmissions Reduction Program.  N Engl J Med. 2016;374(16):1543-1551. doi:10.1056/NEJMsa1513024PubMedGoogle ScholarCrossref
3.
Ibrahim  AM, Nathan  H, Thumma  JR, Dimick  JB.  Impact of the Hospital Readmission Reduction Program on surgical readmissions among Medicare beneficiaries.  Ann Surg. 2017;266(4):617-624. doi:10.1097/SLA.0000000000002368PubMedGoogle ScholarCrossref
4.
Ibrahim  AM, Dimick  JB, Sinha  SS, Hollingsworth  JM, Nuliyalu  U, Ryan  AM.  Association of coded severity with readmission reduction after the Hospital Readmissions Reduction Program.  JAMA Intern Med. 2018;178(2):290-292. doi:10.1001/jamainternmed.2017.6148PubMedGoogle ScholarCrossref
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Jha  AK.  Death, readmissions, and getting policy right.  JAMA Netw Open. 2018;1(5):e182776. doi:10.1001/jamanetworkopen.2018.2776PubMedGoogle ScholarCrossref
6.
Ody  C, Msall  L, Dafny  LS, Grabowski  DC, Cutler  DM.  Decreases in readmissions credited to Medicare’s program to reduce hospital readmissions have been overstated.  Health Aff (Millwood). 2019;38(1):36-43. doi:10.1377/hlthaff.2018.05178PubMedGoogle ScholarCrossref
7.
Ramaswamy  A, Marchese  M, Cole  AP,  et al.  Comparison of hospital readmission after total hip and total knee arthroplasty vs spinal surgery after implementation of the Hospital Readmissions Reduction Program.  JAMA Netw Open. 2019;2(5):e194634. doi:10.1001/jamanetworkopen.2019.4634Google Scholar
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