In this episode, Dr. Ambarish Pandey of the University of Texas Southwestern Medical Center discusses the findings of a study that looked at the association of the quality metric that the Hospital Readmissions Reduction Program uses with long-term clinical outcomes.
Mike Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast.
Today, I’m joined by Dr. Ambarish Pandey, the lead author of a study published in the July 2017 issue of JAMA Cardiology entitled Association of U.S. Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric with Care Quality and Outcomes after Acute Myocardial Infarction.
Dr. Pandey has joined us on the podcast today to talk about the results of that study.
Dr. Pandey is currently a fellow at the University of Texas Southwestern Medical Center.
Dr. Pandey, welcome to the Hospital Finance Podcast.
Dr. Ambarish Pandey: Thanks a lot for having me. And thanks for your interest in our work.
Mike Passanante: So, let’s start out. First, can you briefly explain for listeners who may not be familiar with it what the Hospital Readmissions Reduction Program is, and then why you and your colleagues chose to initiate this study.
Dr. Ambarish Pandey: Yeah, that’s a good starting point.
So, the Hospital Readmissions Reduction Program is a program that was launched by the Center for Medicare and Medicaid Services or CMS as part of the Affordable Care Act.
And under this program, hospitals are ranked based on their readmission rates, mostly 30-day readmission rates, and they are compared within the pool of all US hospitals.
And centers who have higher than expected 30-day readmission rates for common conditions such as heart attack, heart failure and pneumonia are penalized a certain proportion of their Medicare reimbursement as an incentive to drive down the readmission rates.
The first cycle was I think it was implemented in 2012. And it was based on the three years 30-day readmission rate from the previous three years of the first cycle.
Over time, the amount of penalty has gone up. It started with 1% of the Medicare reimbursement charged as the penalty. And now I think it’s as high as 3% or 4%. And the number of conditions that are covered under the Hospital Readmissions Reduction Program, originally, there were only three conditions, and now there are six or more than that.
So, overall, it has grown quite a bit in the past few years.
Mike Passanante: And what were you and your colleagues specifically looking at when you initiated the study?
Dr. Ambarish Pandey: So, basically, what we were interested in looking at was whether or not the quality metric that the Hospital Readmissions Reduction Program uses, which is the risk-adjusted 30-day readmission rate, whether this is associated with long-term clinical outcomes and also with the quality of care that patients get during the index hospitalization.
Basically, there’s not much data to suggest that 30-day readmission is actually clinically meaningful or is actually associated with the quality of care the hospitals provide.
So, we wanted to test that. If the hospitals can be held accountable for a metric whether or not it matters for the patients in the long-term, when it is modifiable by the care that the hospital is providing index hospitalization.
Mike Passanante: And just to get us started with the study, can you briefly go over your methods and data sources?
Dr. Ambarish Pandey: Yeah. So, we used the ACTION Get with the Guidelines NCDR registry data. NCDR is a US-based registry of voluntary participating hospitals that provide the data on patient that is admitted for myocardial infarction and different data regarding their quality of care, what treatment they got.
ACTION is part of the NCDR. It’s basically designed to improve quality of care for myocardial infarction in these hospitals.
The data set that we used within the ACTION was data so that we could get one year results, one year follow-up outcomes on patients who were admitted with myocardial infarction during the time period of the first cycle of HRRP or the Hospital Readmissions Reduction Program. In an effort to capture how patients did over one year based on whether or not the hospitals were penalized.
Mike Passanante: And we’ll dig into some details as we go here. But at a high level, what were the results of the study?
Dr. Ambarish Pandey: Basically, the end results that we observed in our study were that, number one, we saw a significant difference in the patient demographic profile and the severity of the myocardial infarction presentation at centers who did versus who did not get penalized such that centers who had high 30-day readmission rates who were more likely to get penalized had sicker patients and had more commonly African-American patients in non-profit centers who had the lower 30-day readmission rate and did not get penalized.
We also observed that there was no difference in the care quality metrics that the American College of Cardiology and the American Heart Association endorsed for centers with higher versus lower 30-day readmission rates.
And also, finally, we saw that the 30-day readmission rates are risk-adjusted, so that the readmission rates were not associated with one year mortality and also readmissions after the first 30 days within the first year, suggesting that even though centers are penalized for supposedly performing bad on the 30-day readmission metric, there were not any different in terms of one year outcomes or in terms of the care quality that was provided.
So, those were the main findings that we saw.
Mike Passanante: And in the discussion at the end of the study, there was a suggestion that CMS readmissions penalties are perhaps not being equitably applied to hospitals with a prevalence of socially or medically complex patients.
Can you explain why that maybe?
Dr. Ambarish Pandey: Yeah, that was one of the key findings that we wanted to highlight. And basically, what we saw was that centers that treat more African-Americans and more sicker patients were getting penalized despite providing comparable care as well as having comparable clinical outcomes at one year, which suggests that even if a hospital has a comparable care to a second hospital, just based on the demographics of the patients they treat and the medical complexity of the disease burden they see, they are more likely to get penalized.
And I think this is an important finding. It highlights that the CMS metric that is being used currently to incentivize a reduction in readmission rates may not be equitably penalizing the hospitals and centers which treat disproportionate share index hospitals which treat more lower socioeconomic status patients and more sicker patients may be getting the brunt of the penalty.
And they also have lower resources lower resources, so this becomes a vicious cycle. Centers that treat sicker patients that have lower resources at their disposal are getting penalized more. And thus, they have less amount of resources available after the penalty to further improve their care quality.
Mike Passanante: It seems from the study that readmissions associated with MI all cause readmissions or mortality were most closely linked with events occurring within the first 30 days of discharge. What does this finding tell us?
Dr. Ambarish Pandey: So, basically, what we saw was that on mortality, 30-day readmission was not associated with mortality at one year at all.
For readmissions, we saw that 30-day readmissions were associated with readmission rates within one year, but it was all driven by the admissions that happened within the first 30 days.
So, basically, if you landmark and look beyond the first 30 days, the penalty status or how a hospital performs within the first 30 days does not tell you anything about how it will perform in the long term after the first month.
And thus, it is not a sensitive or a specific metric to comment on how hospital outcomes are in the long run and within a hospital doing a good job or a bad job in the long run.
Mike Passanante: Dr. Pandey, could you discuss the potential implications of your study on health policy?
Dr. Ambarish Pandey: That’s a great question. I think the main health policy implication that we think our study had is that it highlights the inequitable distribution of the 30-day readmission penalties such that centers that may be treating more socioeconomically disadvantaged patients and sicker patients are being penalized more despite providing comparable quality of care and having comparable long-term outcomes.
So, we believe that the Readmission Incentive Policy or the Hospital Readmissions Reduction Program needs to be re-evaluated and tweaked around to account for the differences in the socioeconomic status of the patients treated at the different hospitals, and also to account in a better way for the severity of patients presenting at the hospital, so that we can actually bridge this gap and diffuse the inequity in the distribution of the penalty.
Mike Passanante: Dr. Pandey, thank you for your contribution of this study to the discussion. I’m sure it will have implications as CMS continues to look at these programs going forward.
Thank you for joining the Hospital Finance Podcast today.
Dr. Ambarish Pandey: Yeah, thanks a lot for having me an interest in our study. Thank you.