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A Team of MD Leaders Calls for the Phase-Out of the Readmissions Reduction Program

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Is it time for healthcare policy leaders—and the leaders of patient care organizations—to move beyond inpatient readmissions reduction as a core measure of quality performance? That’s precisely what three physicians who are healthcare policy leaders, say in an op-ed online in the JAMA Network.

Indeed, the very title of the piece by Peter Cram, MD, Robert M. Wachter, MD, and Bruce E. Landon, MD, is conveyed in the headline of the article, “Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns?”—which was published online in the “Viewpoint” section of the JAMA Network on Oct. 6.

What’s more, these are prominent physicians, particularly Dr.Wachterwho is chair of the Department of Medicine in the School of Medicine at the University of California, San Francisco, and who is well-known for having authored the 2017 book The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. Meanwhile, Dr. Cram is chair of Internal Medicine at the University of Texas Medical Branch at Galveston (UTMB); and Dr. Landon is a professor of healthcare policy in the Department of Health Care Policy at Harvard Medical School; and Dr. Landon is a professor of medicine and a practicing internist at Beth Israel Deaconess Medical Center (Boston).

And these three healthcare policy leaders are clear on their contention in their JAMA Network op-ed, as they write that, “In this Viewpoint, we argue that the persistent focus on readmissions during the past decade, although undoubtedly leading to some improvements in care , has had minimal demonstrable benefit. Moreover, the HRRP [Hospital Readmissions Reduction Program] has distracted clinicians and health system leaders from other crucial quality concerns. As with many other quality measures, the HRRP has led to gamesmanship (described below) whereby hospitals have taken predictable actions in their coding practices and admission processes and protocols in an effort to minimize the probability of receiving penalties. It is time to refocus hospital quality improvement efforts where they can be most effective and beneficial, which means deemphasizing the HRRP.”

The authors of the article note that, “In a 2009 study, Jencks et al reported that among 11.8 million Medicare beneficiaries who were hospitalized in 2003 to 2004, 19.6 percent were readmitted in the first month after the hospitalization, and these readmissions accounted for an estimated cost of $41 billion annually. Researchers and policy makers inferred that if a significant proportion of readmissions was caused by failures of the health care system—whether due to inadequate treatment during the initial hospitalization or failure of care coordination after hospital discharge—then the adoption of policies designed to reduce inappropriate readmissions would be warranted, particularly because hospitals receive additional payments when patients are readmitted.” Not only did the Jencks study lead to an intense focus on readmissions as a core indicator of the quality of inpatient care; the HRRP ended up becoming embedded in the Affordable Care Act (ACA) in 2010, thus becoming concretized policy, with a system of payment reductions created to punish hospitals with overly high readmissions rates.

Now, though? Cram, Wachter, and Landon write that “[A] growing body of literature now suggests that the reported reductions in readmissions may have been overstated. Wadhera et al found that an increasing number of patients who previously would have been readmitted instead were treated under observation status. Other investigators found that much of the purported reduction in readmissions could be explained by a concurrent change in billing standards that allowed hospitals to submit a larger number of comorbid diagnoses when submitting claims, thereby increasing the expected number of readmissions. Moreover, McWilliams et al found that much of the reduction in readmissions could be explained by contemporary reductions in the rate of hospital admissions for all Medicare beneficiaries. Several studies also reported that HRRP was associated with a small but significant increase in post-discharge mortality for patients with pneumonia and congestive heart failure, although there is disagreement on this point.”

The key element in all this, they believe, is that, “In the decade since implementation of HRRP, there has been greater understanding of why health systems have such difficulty preventing readmissions. Graham et al10 found that less than 36 percent of early readmissions (within 7 days of discharge) and 23 percent of late ones (8-30 days after discharge) were preventable. Moreover, hospitals were identified as the ideal location to target these preventable readmissions in less than half (47 percent) of early readmissions and 26 percent of late readmissions. Alternatively, the patient’s home was identified as the ideal target in 14 percent of early readmissions and 19 percent of late ones; outpatient clinic, in 7 percent and 15 percent, respectively; and emergency department, in 4 percent for both. There also have been significant gains in appreciation of the critical contribution of disadvantage and adverse social determinants of health in driving hospital readmissions at both the individual and hospital level.”

In that context, they write, “Given the challenge of making hospitals responsible for preventing readmissions and the limited success of HRRP, it is important to question whether health systems might be better served by directing their limited quality improvement resources, including both personnel and financial investments, toward improving aspects of care that they control more directly.”

The three physicians believe that, while readmissions reduction-based measures should not be eliminated entirely. “Rather,” they write, “readmissions should continue to be measured and tracked, but the financial penalties associated with HRRP could be withdrawn.” They recommend that HRRP be phased out over time and that “an array of patient safety practices with significantly stronger evidence-based support than readmissions” identified by a 2013 Agency for Healthcare Research and Quality expert panel, be considered for measurement instead. Those measures were “preoperative surgical and anesthesia checklists, clinical bundles and order sets to prevent catheter-associated infections, and expanded use of clinical pharmacists to reduce adverse drug events.” They add that “Other potential opportunities for improvement, such as clinician and hospital personnel wellness, patient experience, addiction treatment services, and palliative care, also warrant attention.”

In the end, the authors conclude that, “In 2010, reducing hospital readmissions appeared to be a fruitful target for quality improvement. In 2022, after more than a decade of concerted effort, it is time to focus limited hospital resources on more tractable and evidence-based targets that are more directly under the control of hospitals.”

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