Mortality Rates Rose After HRRP Value-Based Penalty Enforced

November 20, 2017 - Short and long-term mortality rates increased for Medicare beneficiaries hospitalized for heart failure after Medicare implemented the value-based penalty component of the Hospital Readmission Reduction Program (HRRP), a new JAMA Cardiology study uncovered.

The HRRP penalizes hospitals up to 3 percent of their Medicare reimbursement if the organization has excessive 30-day readmission rates for six conditions, including acute myocardial infarction, heart failure, pneumonia, and chronic obstructive pulmonary disease. The program also added elective total hip and/or knee replacements and coronary artery bypass graft surgery as qualifying procedures.

After the HRRP enforced value-based penalties in 2013, readmission rates started to decrease for heart failure patients. The unadjusted 30-day all-cause readmission rate for heart failure patients dropped from 20.1 percent in the non-penalty phase to 18.7 percent, researchers found using data from the American Heart Association’s Get With The Guidelines-Heart Failure registry and linked Medicare Part A inpatient fee-for-service claims files.

Similarly, the unadjusted one-year all-cause readmission rate declined from 61 percent before the HRRP added penalties to 57.9 percent after the program included value-based penalties.

While value-based penalties in the HRRP reduced short and long-term hospital readmissions, mortality rates increased. The unadjusted 30-day mortality rate jumped from 7.6 percent before HRRP penalties to 9.3 percent after implementation.

READ MORE: Best Practices for Value-Based Purchasing Implementation

Long-term mortality rates followed a similar trend. The unadjusted one-year mortality rate rose from 34.5 percent to 38.1 percent after HRRP value-based penalty implementation.

“The results persisted despite extensive risk adjustment with prospectively captured clinical data and consideration of hospice use,” researchers added.

The study’s findings seem to counter the results of another recent JAMA analysis. Yale New Haven Health researchers reported that declines in 30-day hospital readmission rates for three HRRP conditions (including heart failure) was weakly, but still meaningfully correlated with reductions in 30-day mortality rates.

However, researchers in the JAMA Cardiology study commented that that 30-day risk-adjusted mortality rates after discharge did increase for heart failure patients in the Yale New Haven Health analysis. The analysis showed that the mortality rate increased by 1.3 percent between 2008 and 2014.

The study’s findings raise concerns that the value-based penalty program may be successful with incentivizing hospitals to reduce readmissions. However, the incentives may be jeopardizing the survival of heart failure patients.

READ MORE: Are Medicare Value-Based Penalties Fair to Safety Net Hospitals?

Researchers identified three reasons that may be driving the unintended increase in short and long-term mortality rates.

First, the value-based penalties in the HRRP may incentivize hospitals to “game” the system to reduce readmission rates. Hospitals can game the system by delaying admissions beyond day 30, boosting observation stays, and shifting inpatient care to emergency departments.

A 2016 New England Journal of Medicine study showed potential gaming strategies among hospitals treating Medicare beneficiaries. Researchers reported a 3.1 percent decline in within-hospital readmission rates and a 0.8 percent growth in within-hospital observation stays.

The study also uncovered that the rate of observation stays for HRRP conditions increased significantly faster after the HRRP implemented value-based penalties. Non-HRRP conditions did not follow this trend.

“Further research is needed to examine the association of these ‘gaming’ strategies for reducing readmission rates with mortality risk,” the study stated.

READ MORE: Preparing the Healthcare Revenue Cycle for Value-Based Care

Second, the value-based penalties may take away resources from safety-net hospitals and academic medical centers that could be used to improve care for the most vulnerable and sickest patient populations. Hospitals that take on a greater proportion of patients with socioeconomic disadvantages are more likely to receive a value-based penalty under the HRRP, a recent JAMA Cardiology report revealed.

Although, the most recent study found that 30-day and one-year mortality risks increased at both teaching and non-teaching hospitals. Stakeholders should continue to examine if value-based penalties impede safety-net hospitals and academic medical centers from providing care for disadvantaged populations.

Third, researchers explained that competing risk of hospital readmissions and mortality may be to blame for increasing short and long-term mortality rates. The competing risk was that hospitals with greater short-term mortality rates would have fewer patients to readmit.

However, competing risk is the weakest driver of increasing mortality risk because the study excluded patients who suffered in-hospital mortality.

“In addition, our study demonstrated an increase in not only short-term 30-day mortality, which is of main concern for competing risk, but also in long-term one-year mortality,” the study stated. “Therefore, it is unlikely that competing risk accounted for the divergent trends in readmissions and mortality rates in our study.”

Researchers concluded that Medicare may want to reconsider using heart failure as a condition in the HRRP if further examination shows that value-based penalties in the program result in unintended mortality rate increases.