Hospital Revisits Increased Under Hospital Readmissions Program

August 20, 2019 - While hospital readmissions for targeted diseases fell under Medicare’s Hospital Readmission Reduction Program (HRRP), total hospital revisits within 30 days of discharge increased following program implementation, researchers from Beth Israel Deaconess Medical Center (BIDMC) found.

Total hospital revisits  – which included emergency department visits, observation stays, and inpatient readmissions –  increased for Medicare beneficiaries admitted to the hospital for heart failure, acute myocardial infarction, and pneumonia between 2012 and 2015, the study recently published in the British Medical Journal showed.

Treat-and-discharge visits to the emergency department and observation stays within 30 days of discharge drove the rise in total hospital revisits, which on the national level, exceeded the decline in hospital readmissions, researchers stated.

Increased hospital use during the period was also more pronounced after researchers included all encounters and not just the first revisit within 30 days of discharge from the index hospital stay, they added.

The findings call into question the programs used to reduce hospital readmissions, which are being targeted by healthcare initiatives across the world. In the US specifically, CMS developed the HRRP to reduce Medicare readmissions rates, which cost the program about $26 billion annually, according to data from the Center for Health Information and Analysis.

Under HRRP, CMS motivates hospitals to reduce readmissions using a financial penalty. The program penalizes hospitals up to three percent of their Medicare payments if the facilities have higher than expected 30-day hospital readmission rates. Eighty-two hospitals received the penalty in fiscal year 2019.

Data shows the program achieving its goals. Hospital readmission rates dropped by eight percent nationally from 2010 and 2015, and all but one state decreased their Medicare 30-day readmission rate during the period, CMS reported.

However, the HRRP may not be doing as well as CMS data shows, said Rishi K. Wadhera, MD, MPP, MPhil, the lead author of the BMJ study and an investigator in the Smith Center for Outcomes Research in Cardiology at BIDMC.

“If readmission reductions were solely due to improved discharge planning, care transitions, and post-discharge care, as intended by the HRRP, total hospital revisits would also be expected to fall,” he stated in a press release. “Instead, patients are returning to the hospital more often within 30 days of discharge, and declines in readmissions appear to be due to intensified efforts to manage patients who return in emergency departments and as observation stays.”

Emergency department visits and observation stays help to shift acute care away from the inpatient admission setting. However, evidence shows hospitals that manage more patients in the emergency department versus admitting them for an inpatient stay have higher rates of early death post-discharge, Wadhera and her colleagues reported citing a 2017 study.

The HRRP has already received criticism over associated mortality rates. A 2017 analysis published in JAMA Cardiology found that short and long-term mortality rates increased for Medicare beneficiaries hospitalized for heart failure after CMS implemented HRRP’s financial penalty.

Later research showed no increase of in-hospital or post-discharge mortality rates after CMS implemented the HRRP. But the findings have prompted some researchers to ask if program results have been overstated.

“I would urge renewed skepticism about whether processes to reduce readmissions are in fact working,” Christopher Ody, PhD, professor at the Kellogg School of Management at Northwestern University, recently told RevCycleIntelligence.com.

His research into the program has revealed that evidence showing that readmissions have fallen is flawed, which should prompt practitioners to reexamine the evidence and any workflows that were created based on that flawed evidence, he said.

CMS may better serve Medicare beneficiaries by using more than just 30-day hospital readmission rates to evaluate hospital performance, Wadhera suggested. He advised CMS to consider using 30-day total hospital revisits as a measure to assess quality of care and hospital performance under value-based reimbursement programs.

“Future policy efforts in the US could benefit from measuring total hospital revisits within 30 days of discharge instead of solely focusing on readmissions, to strengthen incentives to improve quality of care and provide a more comprehensive assessment of care quality and healthcare use in the post-discharge period,” the study concluded.