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Opinions on the Hospital Readmission Reduction Program: Results of a National Survey of Hospital Leaders
Karen E. Joynt, MD, MPH; Jose F. Figueroa, MD, MPH; E. John Orav, PhD; and Ashish K. Jha, MD, MPH
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Opinions on the Hospital Readmission Reduction Program: Results of a National Survey of Hospital Leaders

Karen E. Joynt, MD, MPH; Jose F. Figueroa, MD, MPH; E. John Orav, PhD; and Ashish K. Jha, MD, MPH
The Hospital Readmissions Reduction Program has had a major impact on hospital leaders’ efforts to reduce readmission rates; however, important concerns about the program remain.
ABSTRACT

Objectives: To determine the opinions of US hospital leadership on the Hospital Readmissions Reduction Program (HRRP), a national mandatory penalty-for-performance program.

Study Design: We developed a survey about federal readmission policies. We used a stratified sampling design to oversample hospitals in the highest and lowest quintile of performance on readmissions, and hospitals serving a high proportion of minority patients. 

Methods: We surveyed leadership at 1600 US acute care hospitals that were subject to the HRRP, and achieved a 62% response rate. Results were stratified by the size of the HRRP penalty that hospitals received in 2013, and adjusted for nonresponse and sampling strategy.

Results: Compared with 36.1% for public reporting of readmission rates and 23.7% for public reporting of discharge processes, 65.8% of respondents reported that the HRRP had a “great impact” on efforts to reduce readmissions. The most common critique of the HRRP penalty was that it did not adequately account for differences in socioeconomic status between hospitals (75.8% “agree” or “agree strongly”); other concerns included that the penalties were “much too large” (67.7%), and hospitals’ inability to impact patient adherence (64.1%). These sentiments were each more common in leaders of hospitals with higher HRRP penalties.

Conclusions: The HRRP has had a major impact on hospital leaders’ efforts to reduce readmission rates, which has implications for the design of future quality improvement programs. However, leaders are concerned about the size of the penalties, lack of adjustment for socioeconomic and clinical factors, and hospitals’ inability to impact patient adherence and postacute care. These concerns may have implications as policy makers consider changes to the HRRP, as well as to other Medicare value-based payment programs that contain similar readmission metrics.

Am J Manag Care. 2016;22(8):e287-e294
Take-Away Points

Despite the fact that the Hospital Readmissions Reduction Program (HRRP) has increased efforts to reduce readmissions, hospital leaders identified important issues with the program. Our findings from a national survey of hospital leaders indicate that: 
  • Leaders are concerned about the size of the penalties and the lack of adjustment for socioeconomic and clinical factors. 
  • Currently, the HRRP remains a lower priority for leaders than other areas of quality improvement, such as patient safety and adherence to guidelines. 
  • Federal policy makers may want to address these issues as they consider future changes to the program and seek to maximize its impact.
Reducing hospital readmissions has the potential to simultaneously improve patient outcomes and reduce healthcare spending and, as such, has become a major target for US policy makers. In an effort to spur a reduction in readmissions, Medicare began publicly reporting on hospitals’ discharge planning in 2007 and, in 2009, added public reporting on readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Despite these efforts, 30-day readmission rates remained stable near 20% during this time frame.1,2 Consequently, with the passage of the Affordable Care Act in 2010, Congress included legislation establishing the Hospital Readmissions Reduction Program (HRRP).3 Under the HRRP, CMS penalizes hospitals with higher than expected readmission rates for Medicare patients; it has been in effect since the beginning of fiscal year (FY) 2013.4 In the HRRP’s third year, hospitals performing poorly may lose up to 3% of their base Medicare diagnosis-related group (DRG) payments—a substantial amount given that many hospitals have negative Medicare inpatient margins at baseline.5

However, the HRRP has been controversial. Initial reports suggested that the program was more likely to penalize large, teaching, and safety net hospitals.6 Multiple organizations have argued that the program’s methodology should take sociodemographic factors into account and exclude readmissions unrelated to the initial reason for hospitalization,7 and at least 2 bills have been proposed in Congress to address these concerns and others.8,9 On the other hand, early data show that readmission rates have fallen by 1% to 2% since the implementation of the HRRP, suggesting that this program may have had a positive impact on this outcome, although causality cannot be established.1,10,11 

The HRRP is one of a number of value-based payment models within Medicare, and the US Secretary of HHS recently announced a goal to have 85% of Medicare fee-for-service payments tied to quality or value by 2016.12 Many of these new payment programs are closely related to the HRRP; for example, the forthcoming Skilled Nursing Facility Value-Based Payment program is similarly based on a single readmission measure: 30-day readmission following a hospitalization.13 Readmissions metrics similar to the one used in the HRRP are also now included in quality measures for the Medicare Shared Savings Program14 and the Physician Value-Based Modifier Program,15 and will be included in payment programs in additional settings, such as dialysis facilities, in future years.16,17 

Given the importance of the HRRP as a model for future value-based payment programs, its controversy, and its initial success, it is crucial to understand how hospital leaders have responded to the program and closely examine their concerns about its methodology. Therefore, we surveyed hospital leadership—including chief executive officers (CEOs), chief medical officers (CMOs), and chief quality officers (CQOs)—at approximately 1600 hospitals, stratified by whether their hospitals received a penalty under the HRRP. We aimed to answer 3 key questions: first, how has the HRRP impacted hospitals’ readmission reduction efforts, particularly compared with prior readmissions policies such as public reporting? Second, how have leaders prioritized the HRRP in the context of multiple other federal quality improvement initiatives that they face simultaneously? Third, what are the opinions of hospital leaders on the program’s methodology and implementation?

METHODS

Survey Development


Our first step in survey development was to conduct a set of case studies examining hospitals’ efforts to reduce readmission rates; this work has been described previously.18 Based on this work, we developed a survey instrument that was tested with hospital leaders, hospital personnel, and survey experts, and revised accordingly.

Survey Administration

We began in mid-2012 with a list of all acute care hospitals that were eligible for the HRRP, excluding Critical Access Hospitals and other facilities not paid under the Inpatient Prospective Payment System and, thus, ineligible for participation. 

Based on calculations performed prior to survey administration, we anticipated needing 1000 survey responses to have adequate power to address our hypotheses. We anticipated a response rate of 60% to 65%; thus, our final sample consisted of 1600 hospitals. We also designed our survey sample to enable us to pursue secondary analyses that focused on differences between hospitals that care for a large proportion of black patients (who have previously been shown to have particularly high readmission rates19 and are also more likely to face unique challenges18) versus other hospitals; and differences between hospitals that had high, average, or low 30-day readmission rates. Thus, we calculated the overall proportion of Medicare patients at each hospital that self-identified as black. We then calculated 30-day risk-adjusted readmission rates for AMI, HF, and pneumonia, from 2008 to 2010 (the years used to assign hospital penalties during the first year of the HRRP) for each hospital, using methods that have been described previously.20 We selected all of the top 900 hospitals in terms of the highest proportion of black patients hospitalized with either AMI, HF, or pneumonia for inclusion in our sample. We divided the remaining hospitals into 3 groups based on performance on readmissions from 2008 to 2010, which was determined by ranking hospitals with the mean risk-adjusted readmission rates for the 3 target conditions into quintiles: top (best) quintile, middle 3 quintiles, and bottom quintile. We selected 266 hospitals from each of these groups using random number generation. There were a small number of hospitals in our sample that had closed, merged with other hospitals, or become Critical Access Hospitals or long-term care facilities; we replaced these using random selection from the same group.

To identify clinical leaders, we obtained the hospital leadership list of CMOs from the American Hospital Association. Study staff called each hospital leader to verify contact information, and once a recipient was verified, his or her hospital was moved into the active fielding stage. The survey was then fielded in 2 phases. The first phase (June 2013 to June 2014) was conducted by DataStat Inc, of Ann Arbor, MI. A hard copy of the survey was mailed to hospitals, along with a cover letter explaining the intent of the survey and the consent process. This was followed by follow-up phone calls and a second mailing. If requested, recipients were sent a version of the survey as a PDF file. The second phase (June to December 2014) was conducted by research staff at the Harvard T.H. Chan  School of Public Health, and followed a similar protocol—a second mailing and follow-up phone calls—but also gave hospital leaders the option of completing a Web-based version of the survey instrument. The second phase was instituted to ensure an adequately high response rate. Throughout the survey, although the initial point of contact at the hospitals was the office of the CMO, we encouraged that individual to reach out to other leaders within the hospital who were best equipped to help to either provide assistance or actually complete the survey.

Analysis

We computed summary statistics both overall and stratified by HRRP penalty amount. We stratified the hospitals into 3 groups based on their penalty in FY2013, the main time frame in which the survey was in the field. Penalty statuses included a) no penalty, b) minor penalty (greater than 0 but less than the median penalty of 0.32% of base DRG payments), and c) major penalty (equal to or greater than the median penalty). Responses were tabulated for each question. For multiple choice or Likert scale questions, responses were summed within groups as they were defined on the survey (ie, “not important,” “somewhat important,” “very important,” and “extremely important”; or “disagree strongly,” “disagree,” “neither agree nor disagree,” “agree,” or “agree strongly”). For open-ended questions, we created a taxonomy based on the frequency of similar responses, and grouped responses accordingly.

Survey responses were adjusted for both sampling strategy and nonresponse to better reflect a national representation of US hospitals. To adjust for sampling strategy, we assigned sample weights to each group. To adjust for nonresponse, we constructed a logistic regression model, in which, returning the survey was the primary outcome, and hospital characteristics—including size, teaching status, ownership, and urban location—were predictors, as has been done previously.21,22 Each hospital received a likelihood of response based on this model; responses were then weighted with the inverse of this likelihood. Finally, we conducted additional regression analyses, in which, we further adjusted responses for the hospital characteristics listed above, as well as for the safety net status of the hospitals—those hospitals in the top quintile of Disproportionate Share Hospital Index were considered to be in the safety net6,23—and the proportion of black patients at each hospital.

All responses were de-identified before analysis. Informed consent was obtained within the survey itself and the introductory page to the survey included detailed information about privacy and data de-identification, as well as consent, stating, “Completion of this survey implies informed consent.” The study was approved by the Office of Human Research Administration at the Harvard T.H. Chan School of Public Health.

RESULTS

Hospital and Leader Characteristics


Of the 1600 hospitals contacted, we received completed surveys from 992 (62% response rate). Of that group, 951 were eligible for HRRP penalties in FY2013 and, thus, comprise our analytic sample. The other hospitals, mainly those in Maryland, or hospitals that no longer had enough cases to qualify for the program, were not eligible for HRRP. Hospital characteristics differed significantly by penalty receipt, with nonteaching, public, and Northeastern hospitals more likely to be in the “major penalty” group, and higher proportions of black and Medicaid patients in the highly penalized hospitals. Readmission rates were, as expected, higher in the highly penalized hospitals (Table 1).

Compared with nonrespondents, respondents were more often leaders from large, nonprofit, or teaching hospitals; respondents were also more likely to represent urban hospitals and those located in the Northeast and Midwest (eAppendix Table 1 [eAppendices available at www.ajmc.com]).

Of the respondents, 29.6% identified themselves as directors of case management or equivalent, 27.1% as CQOs or equivalent, 26.3% as CMOs or chiefs of staff, 4.6% as chief nursing officers, 2.5% as CEOs, and 9.8% as “other,” including vice president for medical affairs and chief operating officer.

Impact of the HRRP on Efforts to Reduce Readmissions

 
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