Background: Higher rates of 30-day readmissions are associated with lower quality hospital care, and readmissions may put patients at risk for worse health outcomes including death. Historically, 20% of hospitalized Medicare beneficiaries were readmitted within 30 days, and many readmissions appeared avoidable. Accordingly, the Centers for Medicare and Medicaid Services (CMS) implemented the Hospital Readmissions Reduction Program (HRRP) in October 2012, pursuant to the Patient Protection and Affordable Care Act of 2010. The HRRP financially penalizes hospitals with higher readmission rates among fee-for-service Medicare beneficiaries age 65 and above who are admitted with acute myocardial infarction (AMI), heart failure (HF), or pneumonia; additional conditions were added in October 2014 and later. Penalties are based on performance relative to other hospitals over a three-year look-back period, giving all hospitals a reason to improve. Nonetheless, incentives to lower readmissions are greater for penalized hospitals because the penalties can be sizeable, representing up to 1% of payments for all Medicare admissions in the first program year (fiscal year 2013), 2% in the second year, and 3% thereafter.
Methods: We performed an interrupted time series analysis that compared observed trends in risk-adjusted readmission and mortality rates in an “anticipation” period (April 2010 to September 2012) and in an “implementation” period (October 2012 to December 2013), with expected trends based on a “pre-HRRP” period (January 2008 to March 2010). Next, we compared differences in the observed and expected trends between hospitals that incurred penalties and those that did not.
Results: After HRRP implementation at 3,291 hospitals, observed readmission rates declined below expected rates for AMI (Δ -2.3 percentage points, 95% CI -3.3 to -1.2), HF (Δ -2.3 points, 95% CI -3.1 to -1.6), and pneumonia (Δ -2.4 points, 95% CI -3.1 to -1.6) at penalized hospitals; observed rates exceeded expected rates for AMI (Δ 1.7 percentage points, 95% CI 0.3 to 3.1), HF (Δ 1.5 points, 95% CI 0.2 to 2.7), and pneumonia (Δ 2.0 points, 95% CI 0.8 to 3.1) at non-penalized hospitals. For mortality, observed and expected rates were similar for AMI (Δ 0.1 percentage points, 95% CI -0.5 to 0.7) and pneumonia (Δ 0.1 points, 95% CI -0.3 to 0.6). For HF, observed mortality rates exceeded expected rates (Δ 0.7 points, 95% CI 0.4 to 1.1), but observed-to-expected differences were similar between penalized and non-penalized hospitals (ΔΔ -0.30, 95% CI -1.25 to 0.65).
Conclusions: In conclusion, the announcement and implementation of the HRRP coincided with declines in 30-day readmission rates for AMI, HF, and pneumonia at penalized hospitals, and with increases relative to what was expected at non-penalized hospitals. Thirty-day mortality rose relative to what was expected among patients with HF at both penalized and non-penalized hospitals. These trends may not be related to the HRRP. The causes of increasing 30-day mortality rates among patients admitted with HF warrant further investigation.
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