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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.
Nearly two-thirds (65.8%) of hospital leaders reported that the HRRP had a “significant” or “great” impact on increasing their hospital’s efforts to reduce readmissions compared with the 2 readmissions policies that preceded the HRRP: public reporting of readmission rates (36.1%) and public reporting of discharge planning (23.7%). When we examined these opinions, stratified by receipt of a penalty, we found that leaders at hospitals receiving a penalty were much more likely to report that each of the federal policies had impacted their efforts to reduce admissions than at those hospitals not receiving a penalty (Figure 1). Adjusting these results for hospital characteristics and socioeconomic status (SES) factors yielded similar results (eAppendix Figure 1).

In terms of potential responses to the HRRP, 26.6% of leaders reported that it was more than moderately likely that hospitals would increase the use of observation status to improve their perceived performance on readmissions, and 15.1% felt it was more than moderately likely that hospitals would increasingly avoid high-risk patients. These responses were similar across penalty strata (P = .46 and P = .14 for differences in response, respectively).

Prioritization of Readmissions Reduction in the Context of Other Federal Programs

When asked to prioritize readmissions reduction among other current federal quality improvement initiatives, only 44.1% of leaders reported that it was of “highest priority” compared with 79.2% for improving patient safety, 76.6% for improving patient experience, 75.2% for reducing hospital-acquired infections, 65% for meeting Meaningful Use requirements, and 44.4% for improving compliance with guideline-based care. The biggest gap in prioritization between leaders at hospitals with readmission penalties versus without readmission penalties was in prioritizing readmissions. However, leaders at highly penalized hospitals still rated all 6 of the competing priorities more highly than those at nonpenalized hospitals (Figure 2). Results adjusted for hospital characteristics and SES factors were similar (eAppendix Figure 2).

Opinions on the Methodology and Impact of the HRRP

A majority (67.5%) of leaders felt that the HRRP penalties were “much too large”; this was more common among leaders at hospitals receiving major penalties (74.7%) than those hospitals without penalties (65.2%: P <.001) but was still a majority in all groups. The most commonly endorsed critique of the HRRP penalty was that it did not adequately account for differences in SES between hospitals (76.2% “agree” or “agree strongly”). Other common concerns included an inadequate account of medical complexity by the penalty (75.9%), and hospitals' limited ability to impact patient adherence (64.1%) (Table 2). Each concern was expressed more often among leaders of hospitals receiving major or minor penalties than among leaders of hospitals without penalties (Table 2); results adjusted for hospital characteristics and SES factors were similar, although the differences between groups narrowed somewhat (eAppendix Table 2).

Only a minority of study hospitals were participating in bundled payment programs or accountable care organizations (ACOs), and just over half of hospitals were participating in private pay-for-performance programs (Table 3, top panels). When asked whether these value-based payment programs were likely to improve quality, 42.5% of leaders responded affirmatively about the HRRP compared with 32% for bundled payment programs, 45.6% for ACOs, and 52.6% for pay-for-performance (Table 3, bottom panels).

Response patterns were generally similar when stratified by receipt of a penalty, but leaders at hospitals receiving penalties were less likely to respond that the HRRP was likely to improve care (35.7% for hospitals with major penalties vs 45% for minor penalties vs 48.4% for no penalties [Table 3]) and response patterns were also similar when adjusting for hospital characteristics and SES factors (eAppendix Table 3). The highest proportion of respondents (54.8%) felt that the HRRP was likely to reduce costs compared with the other programs (Table 3); responses were similar across penalty strata and after adjustment (eAppendix Table 3).

 

DISCUSSION


In a large, national survey, hospital leaders reported that the HRRP has had a sizable impact on their hospitals’ efforts to reduce readmissions. However, despite paying more attention to readmissions than previously done, hospital leaders continue to prioritize other quality improvement efforts, such as improving patient safety, improving patent experience, and adhering to clinical guidelines. Hospital leaders also reported critiques of the policy—largely centered around risk adjustment for SES and clinical factors—and the ability of hospitals to impact patient adherence, as well as postacute, ambulatory, and institutional care. Leaders at hospitals that were receiving penalties under the HRRP tended to have more negative opinions about the program than leaders at hospitals without penalties.

According to hospital leaders, the HRRP has had a significantly greater impact on their own efforts to reduce readmission rates than its policy predecessors—namely, public reporting of discharge planning and public reporting of readmission rates. This observation, that financial incentives alter behavior to a greater degree than public reporting alone, is consistent with prior observations24 and may explain why the HRRP has been associated with improvements in readmission rates1,10,11 whereas public reporting was not. This experience may suggest that policy makers should move more rapidly to financially reward or penalize hospitals for desired outcomes rather than merely reporting them publicly.25 Of course, the fact that over one-fourth of respondents suggested that hospital leaders might increase the use of observation status to improve performance on readmissions, and 15% thought hospitals might avoid high-risk patients, could serve as cautionary counterpoints to the enthusiasm for financial incentives.

Nevertheless, despite the reported impact of the HRRP, nearly every other mandatory federal quality improvement program was rated higher in terms of its importance in our survey, although the study design did not allow us to determine why this was the case. One possibility is that readmissions were seen by many as being outside the control of the hospital; in the setting of competing priorities, perceiving a lack of ability to change an outcome could cause hospital leadership to focus on other areas for intervention. As programs, such as ACOs, increasingly bridge the inpatient and outpatient settings, it is possible that increasing integration could alter these perceptions. Additionally, as the number of Medicare programs that reward readmissions as components of performance continues to grow—not only in ACOs,14 but also including the Physician Value-Based Modifier15 and the coming pay-for-performance programs in the dialysis16,17 and postacute care settings13—it is feasible that inpatient facilities may prioritize readmission reduction more highly.

In terms of methodology, the frequently cited critiques of the HRRP included its lack of adjustment for SES or patient adherence and concern about its adjustment for medical complexity. Although these findings were not necessarily surprising given prior publications6 and public commentary to this end,26 our survey allows us, for the first time, to quantify the degree to which these are concerns for hospital leaders. Given that more than 3 of 4 hospital leaders reported SES as a critical issue, it is clear that the concerns are not just among those who disproportionately care for the poor. On the other hand, a sizable proportion of leaders did not feel that SES adjustment was necessary, suggesting that support is not unanimous among the hospital community. There is a great deal of current activity around SES and readmission policy: the National Quality Forum recently released recommendations in this area,27 and is currently undertaking analyses to determine if adjustment for SES is appropriate for certain measures, including many having to do with readmissions.28 Two bills that were recently proposed in Congress aimed to incorporate measures of poverty, income, and education into risk adjustment for the HRRP,8,9  but neither legislation has moved forward. The Medicare Payment Advisory Commission has argued that the HRRP should stratify hospitals into groups based on SES,29 which is one promising strategy. Congress also passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act in October 2014, which calls on the HHS to study the relationship between SES and performance in Medicare’s incentive-based programs, and to suggest changes in these programs that might be warranted.30

Limitations

As is the case with all surveys, it is possible that nonrespondents were different than those who responded to our survey. Although we used appropriate techniques to deal with nonresponse, these statistical techniques are imperfect. Further, we believe that hospital leaders answered these questions to the best of their ability, but, nevertheless, there may be differing opinions within hospitals, such that our results reflect only the individual who filled out the instrument. Therefore, it is possible that sampling different individuals within these hospitals would have yielded different results. Finally, we surveyed hospitals during the first 2 years of the HRRP, and leaders’ opinions may change over time.

CONCLUSIONS

In a national survey of hospital leaders, we found that the HRRP has had a major impact on hospital leaders’ efforts to reduce readmissions; however, the HRRP currently remains a lower priority for leaders than other areas of quality improvement, such as patient safety, patient experience, and adherence to guidelines. Further, concerns remain about its manner of accounting for social and medical risk factors and whether hospitals, by themselves, can impact patient adherence or the transitional and postacute care that helps determine whether a patient is readmitted. These findings may be useful for policy makers contemplating future iterations of the HRRP and other programs using readmissions as a quality metric that may have a synergistic effect on improving patient care. 

Author Affiliations: Department of Health Policy and Management (KEJ, JFF, AKJ) and Department of Biostatistics (EJO), Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Internal Medicine (JFF, EJO, AKJ) and Division of Cardiovascular Medicine (KEJ), Department of Medicine, Brigham and Women’s Hospital, Boston, MA.

Source of Funding: This research was funded by NHLBI grant number 1R01HL113567-01.

Author Disclosures: Dr Joynt is currently employed in the United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, where Dr Orav also serves as an advisor. The work described here was conducted when the authors were employees of Harvard University. The views expressed herein are those of the authors alone, and do not represent the official position of the federal government. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (KEJ, JFF, AKJ); acquisition of data (AKJ); analysis and interpretation of data (KEJ, JFF, JO, AKJ); drafting of the manuscript (KEJ, JFF, JO, AKJ); critical revision of the manuscript for important intellectual content (KEJ, JFF, JO, AKJ); statistical analysis (KEJ, JFF, JO); provision of patients or study materials (AKJ); obtaining funding (AKJ); administrative, technical, or logistic support (KEJ, JFF); and supervision (AKJ).

Address correspondence to: Karen E. Joynt, MD, MPH, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: kjoynt@hsph.harvard.edu.
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