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The policy
The Hospital Readmissions Reduction Program (HRRP), created by the Affordable Care Act, reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for targeted conditions, which first included heart failure, acute myocardial infarction and pneumonia. Its aim was to push hospitals to improve discharge planning and follow-up.
What it achieved
Zuckerman et al. (2016) analyzed data from 3,387 hospitals. From 2007 to 2015, readmission rates for targeted conditions fell from 21.5% to 17.8%, and for nontargeted conditions from 15.3% to 13.1%. Readmissions declined quickly after the law passed, especially for targeted conditions. Stays in observation units increased over the same period, but hospitals that increased observation stays more did not have larger falls in readmissions, so the authors found no evidence that hospitals were simply relabeling readmissions as observation stays.
The concern
Fewer readmissions don't necessarily mean better care. Wadhera et al. (2018) studied 8.3 million Medicare hospitalizations for the three original conditions. Compared with earlier trends, the program's announcement and implementation were associated with an increase in 30-day mortality after discharge for heart failure and pneumonia, but not for acute myocardial infarction. The increase was concentrated among patients who died within 30 days of discharge without being readmitted. Mortality within 45 days of admission didn't increase significantly, and because the study was observational, the authors called for more research into whether the policy caused the increase.
Analysis
| Criterion | Assessment |
|---|---|
| Effectiveness | Readmissions fell for both targeted and nontargeted conditions |
| Unintended consequences | Possible increase in post-discharge mortality for heart failure and pneumonia, which needs further study |
| Equity | Hospitals serving more low-income patients face higher penalties, because social factors affect readmissions. From fiscal year 2019, the program has compared hospitals with peers serving similar proportions of patients eligible for both Medicare and Medicaid |
| Feasibility | Uses existing claims data, so it is simple to administer |
The nurse's role in advocacy
Nurses see how payment policies change care at the bedside. MSN-prepared nurses can:
- Share evidence with policymakers, through professional organizations' comment letters on Medicare payment rules, about pairing readmission measures with mortality measures so hospitals aren't rewarded for avoiding readmissions at any cost.
- Lead hospital responses that improve care, such as nurse-led transitional care, rather than responses that only reduce readmissions on paper.
- Monitor local data, including deaths after discharge, to make sure efforts to cut readmissions don't harm patients.
- Advocate for equity, including community investment and social risk adjustment for safety-net hospitals.
Conclusion
The HRRP shows both the power and the risk of payment incentives. Readmissions fell, but measuring only one outcome may have pushed some care in the wrong direction. Nurses can help keep the focus on what matters most to patients: surviving and recovering well after they go home.
References
Wadhera, R. K., Joynt Maddox, K. E., Wasfy, J. H., Haneuse, S., Shen, C., & Yeh, R. W. (2018). Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA, 320(24), 2542–2552. https://doi.org/10.1001/jama.2018.19232
Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine, 374(16), 1543–1551. https://doi.org/10.1056/NEJMsa1513024
