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64 QUALITY IMPROVEMENT & MEASUREMENT Readmission Reduction Program Persistently Penalizes Some Hospitals, Study Finds By Emily Rappleye T he Hospital Readmissions Reduction Program created under the ACA may persistently penalize hospitals with certain character- istics, according to a recent study published in Health Affairs. Researchers analyzed penalty data from 2013 to 2017 for 3,229 hospi- tals, comparing it with hospital characteristic data from the American Hospital Association Annual Survey and CMS impact file data, which includes Medicare disproportionate share hospital information. ey did not include hospitals with missing characteristic data. Here are their main findings. 1. More than half of hospitals in the program (52.4 percent) were penalized all five years. ose penalized year aer year tended to be urban, major teaching, for-profit, large- or medium-sized and more likely to have a higher proportion of Medicare patients. 2. Hospitals treating socioeconomically disadvantaged patients were also more likely to be penalized. Oen so- cioeconomic factors cause readmissions and cannot be captured in claims data, according to the study. e report demonstrated that safety-net hospitals have reduced readmission rates more than non- safety-net hospitals, yet have been unable to improve as much in the program. "Safety-net hospitals play a critical role in treating under- served and vulnerable populations, and policy makers need to be cognizant of the unintended effects of penalty programs on these institutions," the researchers wrote. 3. Low volume of complex cases was also a factor in 5-year penalization. e researchers were surprised to find hospitals with a more complex case mix were actually less likely to be penalized all five years than those with a smaller proportion of complex patients. Hospi- tals with complex case mixes generally started out with lower penalties and their penalty increases over time were also smaller compared to hospitals with less complex case mixes. "ese findings are somewhat paradoxical, as more medically complex patients are more likely to be readmitted following discharge," the authors wrote. "It may be that hospitals treating more medically complex patients already have infra- structure in place to prevent readmissions and, therefore, fared better under the HRRP compared to their peers." 4. Hospitals penalized in the first year of the program were more likely to continue to be penalized, and to be penal- ized more, throughout the program. e study illustrated that hospitals that fell behind early had difficulty catching up. "[E]ven if hospitals made improvements in readmission rates over time, they con- tinued to receive penalties if they were unable to make comparatively greater reductions in readmissions," the authors wrote. 5. Penalties grew a little bit over the five years stud- ied, from 0.29 percent in 2013 to 0.60 percent in 2017. Though this means the penalties doubled, the research- ers classified this growth as only "modest" because the program ramped up over the 5-year time period, so that hospitals actually had more ways to be penalized by the end of the period. e researchers concluded the HRRP led to persistent penalization and that CMS should consider alternative ways to structure the program. "Persistent penalization could have a sizable financial impact on partic- ular hospitals, limiting their ability to meet the needs of the populations they serve and invest in quality improvement activities," they wrote. n CMS Readmission Penalties Don't Correlate With Outcomes, Are Unfair to Hospitals With Sicker Patients, Study Says By Brian Zimmerman T he CMS Hospital Readmissions Reduction Program may unfairly level 30-day readmission penalties against hospitals that care for more severely ill pa- tient populations, according to a study published in JAMA Cardiology. For the study, researchers examined one-year heart attack outcomes for more than 50,000 patients treated at 377 hospitals. Researchers identified no difference in one-year mortality rates and long-term readmission rates between hospitals deemed to have high readmission rates per the 30-day standard. "The current CMS readmission metric does not correlate with long-term clinical outcomes," said Ambarish Pandey, MD, a cardiologist with the University of Texas Southwest- ern Medical Center in Dallas and one of the study's authors. Analysis also revealed the hospitals most often penalized for 30-day heart attack readmissions were those serving larger ethnic minority patient populations and patients af- flicted with more severe illnesses. "Our findings raise concern about the fair and equitable al- location of CMS penalties for readmissions," said James de Lemos, MD, PhD, associate director of the cardiovascular fellowship program at UT Southwestern Medical Center in Dallas and the senior author of the study. "It is fundamen- tally unfair to penalize hospitals for factors that are beyond their control. We support proposed changes to pay for performance that would consider socioeconomic status in the risk-adjustment methods to calculate rewards and penalties." The new study adds to a growing body of research that sug- gests the CMS readmission reduction program is unfair. n