Readmissions penalties don't increase mortality rates

A study from the Medicare Payment Advisory Commission (MedPAC) found the Hospital Readmissions Reduction Program (HRRP) has largely achieved its goals—and contrary to the findings of an earlier study, it didn’t increase mortality rates.

Hospitals had been alarmed by a Nov. 2017 study in JAMA Cardiology which linked HRRP to higher mortality rates among heart failure patients. Researchers who studied more than 115,000 Medicare beneficiaries across 416 hospitals found while 30-day readmission rates declined after HRRP began penalizing hospitals, risk-adjusted mortality increased from 7.2 to 8.6 percent at 30 days, and from 31.3 to 36.3 percent at one year. The implication was hospitals may be turning away necessary readmissions in order to avoid being penalized.

The study from MedPAC analysts Craig Lisk, MS, and Jeff Stensland, PhD, didn’t match those findings. In their research presented at MedPAC’s January meeting (the same meeting where the commission recommended repealing the Merit-based Incentive Payment System), they said the increase in mortality among heart failure patients was in the raw, not risk-adjusted rates.

“As easier cases are no longer admitted to the hospital, patient complexity increases and we would expect an increase in the raw, meaning not risk-adjusted mortality,” Stensland said. “Given the declines in initial admissions we see, increasing raw mortality rates should not be unexpected.”

For other HRRP conditions like pneumonia and acute myocardial infarction (AMI), the raw mortality rates actually declined. For risk-adjusted mortality rates, however, the results showed a decline among all five conditions included in HRRP.

“The bottom line is that the data we have suggest that declines in readmissions are not causing increases in mortality,” Stensland said.

The declines in risk-adjusted readmissions are “largely real,” the study said, and can’t be attributed entirely to coding. Admissions per capita declined 17 percent between 2010 and 2016 and there were fewer one-day stays likely due to some less severely ill patients being shifted to observation care. Hospitals which had bigger readmissions decline were more likely to have larger increases in observation and emergency department visits, but Lisk said HRRP only explains about “3 percent of the variation” in those changes.

The program also appeared to achieve its goal for lowering Medicare spending. While there were small increases in payments for observation stays and ED visits, the reduced readmissions overall saved Medicare $2 billion in 2016.

“Now while the program is not perfect, it has appeared to generate some benefits for patients and taxpayers,” Stensland said. “Patients benefit by not having to endure as many admissions. Patients spend less time in the hospital and appearing to have at least equal outcomes.”

Stensland added that the commission will be discussing how to address some of the program’s imperfections at its spring meeting.