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Debate Over 30-Day Readmission Metric Dominates Quality Session


A session at the 68th American College of Cardiology Scientific Session continues the ongoing debate whether a CMS reimbursement model has contributed to rising mortality in patients with heart failure.

Nearly 18 months ago, cardiologist Gregg Fonarow, MD, FACC, FAHA, FHFSA, turned a decade-old discussion about value-based care on its head when he was senior author for a JAMA Cardiology article that challenged a core quality measure: the need to reduce readmission rates within 30 days of a hospital stay.

The University of California at Los Angeles physician and his co-authors found that the penalties tied to CMS’ Hospital Readmission Reduction Program (HRRP) were changing behavior, and in ways that were not good for patients. Under the HRRP, the stakes for an individual health system were steep: up to 3% of Medicare revenues could be on the line if readmission rates fall short.

So, Fonarow said, administrators learned to “game” the system to avoid losing money—patients who showed up at the emergency department (ED) would be held in observation for hours, sometimes days. People simply would not be admitted. Fonarow said forced referrals to hospice increased. And all of this contributed to rising mortality for patients with heart failure, among the sickest in the health system.

Fonarow has continued to publish and speak on this topic, and on Saturday he addressed it for the second straight year during the annual gathering of the American College of Cardiology, being held in New Orleans, Louisiana. Billed a debate with Stanford’s Paul Heidenreich, MD, MS, FACC, during the session, “The Right Quality Metrics and Performance Metrics and Right Outcomes in Heart Failure,” Fonarow presented new data that he said show the 30-day readmission metric continues to work against the most vulnerable patients.

On a slide, “What policymakers have told you,” Fonarow took issue with what he said are CMS’ claims of success and savings, including that “the majority of 30-day readmissions could be easily prevented,” and “there has been no credible evidence for harm.”

A marked increase in upcoding obscures what’s really happening, he said, citing data from a 2018 study in JAMA Internal Medicine. His presentation highlighted Medicare’s focus on how its value-based programs tout savings, which Fonarow said is largely penalties; in 2017, this amounted to $528 million levied against 79% of the US acute care health systems. “I’m going to use data reported by government, which I know everyone consistently trusts,” Fonarow said, as he went through a list of statistics showing how hospitals that have reduced the 30-day risk standardized readmission rate measure also have worse process of care measures. And they have worse mortality measures at 30 days, 90 days, 1 year, 3 years and 5 years.

With so many of the CMS quality measures in the HRRP tied to their field, cardiologists were among the first to complain that CMS quality measure failed to take patient socioeconomic factors into account. Research presented at ACC in 2015 found that when hospitals were evaluated on cardiac process measures, many urban academic medical centers outperformed their suburban counterparts, but they could not overcome population factors such as diabetes and smoking that affected mortality rates.

Fonarow said the readmission measure as it exists today doesn’t factor in the competing risk of patient mortality. That means there’s no financial penalty if a patient dies, but “those places that do a better job of taking care of patients have higher 30-day readmission rates,” and lose money as a result. “Higher quality care should be financially rewarded,” Fonarow said.

In a rebuttal, Heidenreich said it’s important to separate the need to measure readmission as an indicator of quality, and separate this from the HRRP incentive program. “Can we use readmission in a way that is helpful to patients and the system?” he asked.

Heidenreich did not disagree that a better metric would combine readmission rates with a mortality measure—or even process measure and patient reported outcomes. And he said that it’s worth asking whether the HRRP is actually responsible for rising mortality in heart failure, if readmissions have not fallen enough overall to account for the uptick that Fonarow cited. A reimbursement system that rewards or punishes systems for readmission rates would eliminate rankings and instead set a standard; only those that fail to meet the bar would be penalized, perhaps 5% of the systems that are outliers.

In the end, Heindenreich said, it’s not measuring readmissions is a problem—it’s the way the measure has been connected to reimbursement. To prove his point, he cited a 1997 paper that found, “Hospital readmission represents a useful outcome for analysis reflecting both the frequency of clinical decompensation and the major component of cost for heart failure.”

Who was the lead author? None other than Gregg C. Fonarow, MD.

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