Value-Based Care News

CMS Value-Based Purchasing Not Behind Hospital Readmission Decline

A new analysis links a drop in hospital readmission rates from 2009 to 2014 to a decline in hospital admissions, not CMS’ value-based purchasing program.

Value-based purchasing and hospital readmissions

Source: Getty Images

By Jacqueline LaPointe

- A value-based purchasing program run by CMS has been credited with the drop in 30-day hospital readmission rates through 2014. But a new analysis led by researchers at Harvard Medical School offers an alternative explanation for the decline.

Published in the November issue of Health Affairs, the analysis suggests that an overall drop in hospital admissions – which fell by 12.1 percent from 2009 to 2014 according to the study – may be behind the observed reduction in hospital readmissions.

“The decline in readmission rates looked like the silver lining of pay-for-performance, but it seems to have lost its luster,” the study’s lead author J. Michael McWilliams, the Warren Alpert Foundation Professor of Health Care Policy in the Blavatnik Institute at Harvard Medical School, stated in a press release. “Our study makes a strong case that what looked like achievements of the program may have been a byproduct of factors driving a broader decrease in hospitalizations across the board.”

To determine the relationship between hospital admissions and 30-day readmissions, McWilliams and her team ran a simulation analysis using fee-for-service Medicare claims data from 2009 to 2014 for a 20 percent sample of Medicare beneficiaries.

They first calculated changes in per capita readmission rates during the period and removed random samples of admissions form the 2009 claims data to match national trends. From there, they recalculated readmission rates to determine what would be expected at the lower admission rate. The analysis included almost 6.4 million admissions among nearly 2.6 million beneficiaries.

Researchers assumed that 30-day hospital readmission rates would decrease as admission rates declined based on the assumption that deficient quality of care in prior admissions were not driving the majority of readmissions.

The simulation analysis confirmed their theory, revealing a substantial link between decreases in readmission rates and declining admission rates. Researchers observed a similar trend in an alternative analysis that reflected changes in case-mix of admitted patients.

But even if readmissions were caused entirely by deficient quality of care during prior admissions, simulated hospital readmission rates through 2014 did not decrease. Rather, the rates remained close to the observed rate in 2009, researchers reported.

“These findings would not be expected from quality improvement efforts that specifically targeted readmissions in response to HRRP incentives, but they all are consistent with broad decreases in admission rates causing readmission rates to fall,” researchers wrote in the analysis.

“Readmission reduction efforts could have plausibly contributed to some decline in admission rates but are unlikely to explain a large all-payer decline in admissions,” they continued. “Therefore, our findings question the extent to which recent readmission reductions can be attributed to readmission-specific incentives and initiatives.”

The analysis adds to a growing body of literature questioning the efficacy of the HRRP.

Earlier this year, for example, researchers from Northwestern University, University of Chicago, and Harvard University called HRRP results “illusory or overstated.” Their study, which was also published in Health Affairs, attributed drops in readmission rates after HRRP implementation to a coding change that allowed hospitals to submit secondary diagnoses on Medicare claims, not value-based purchasing incentives.

Increases in patient risk scores stemming from improved clinical documentation and coding may have also driven decreases in hospital readmission rates after HRRP implementation, a 2018 analysis revealed.

“While new payment models may play a key role in containing health care costs, attempts to improve quality through the payment system are fraught and may not be the key to quality improvement,” McWilliams said. “Rather, I tend to think we are better off devoting our attention and energy to understanding what improves care and outcomes. Once we know what works, there should be demand for it.”