Data Presented at AHA Shows Medicare's HRRP Only Cut Readmissions for the Wealthy

Medicare's Hospital Readmission Reduction Program (HRRP) a centerpiece of CMS' protocol to evaluate hospital quality, has mostly worked to reduce readmissions among the wealthiest patients, while readmissions continue to climb among the poor, according to data presented today during the American Heart Association (AHA) Scientific Sessions in Chicago.

The data, presented in a poster session, focused on the relationship between neighborhood household income and 30-day readmission rates in patients with HF.¹ The researchers explored whether the HRRP truly had an effect on HF readmissions by comparing readmissions by income level in the years before and after the HRRP took effect.

The study used the National Readmissions Database to find all admissions of adults during the period from 2010 to 2019 with a primary diagnosis of HF who had an unplanned readmission within 30 days. Household income was split into 4 quartiles: low income, middle income, upper-middle income, and high income. All-cause 30-day readmission rates by yearly trend were collected using household income quartile. The pre-HRRP period from 2010 to 2012 was compared with the post-HRRP period from 2013 to 2019 when comparing the adjusted readmission rates.

Adjusted all-cause 30-day readmission rates increased for patients in low-income (18.8% to 19.0%) and middle-income quartiles (17.6% to 17.9%) when evaluating the 9,020,742 index hospitalizations from 2010 to 2019. Readmission rates remained similar in the upper middle-income quartile (17.7% to 17.3%) and decreased in the high-income quartile (16.8% to 16.4%). The association between HRRP and adjusted all-cause readmission varied, with patients in lower quartiles seeing greater increases in readmissions.

“A hospital readmission reduction program that was implemented by the federal government in 2012 has not really taken its true effect,” said Stephen J Greene, MD, an author of the study. “Readmissions continue to increase, especially for those people in the lower quartiles. That can inform us or inform the federal government in their decision making as they try to come up with either an amendment to this policy or a different policy.”

The researchers of this poster concluded that adjusted all-cause 30-day readmission rates were affected by neighborhood household income in patients hospitalized for HF in the United States from 2010 to 2019. Readmission rates also increased for patients in the lowest 2 quartiles, with the greatest overall increases in patients in the lowest quartile.

A second poster evaluated whether neighborhood socioeconomic status (NSES) was able to predict higher rates of HF readmission in a safety-net system.² A retrospective electronic health record-based cohort study was conducted and evaluated adults with HF from 2001 to 2019. All patients were from a municipal safety-net hospital in San Francisco and Fine-Gray survival models were used to conduct the study. Residential addresses were geocoded.

NSES was composed of a patient’s income, education, employment, and housing and scaled to the San Francisco Bay Area in quintiles, with 1 being the lowest and 5 being the highest socioeconomic status.

There were 2507 participants, of which 179 (7.1%) were readmitted within 30 days for HF and 374 (14.9%) were readmitted for any cause. There were 639 participants who were readmitted for HF and 1185 (47.3%) readmitted for any cause within 1 year.

Unadjusted analyses found that NSES was associated with HF readmission and all-cause readmission in 30 days and at 1 year. Quintile 1 had a 58% higher risk of HF readmission (HR, 1.58; 95% CI, 1.07-2.33) and 56% higher risk of all-cause readmission (HR, 1.56; 95% CI, 1.19-2.05) in 1 year when compared with quintile 5 after adjusting for demographics, substance use and comorbidities. All quintiles had a higher risk of all-cause readmission in 1 year compared with quintile 5, including quintile 2 (HR, 1.53; 95% CI, 1.16-2.03) and quintile 4 (HR, 1.50; 95% CI, 1.10-2.03).

The researchers concluded that NSES was associated with a higher risk of HF and all-cause readmissions in 1 year in a safety-net hospital.

Both posters establish evidence that neighborhood socioeconomic status and household income determine health outcomes for patients with a diagnosis of HF.

For years, HF specialists have cried foul over the HRRP, saying it works against safety net hospitals that treat poor patients who arrive with accumulated comorbidities and higher smoking rates, which are more likely to account for higher readmission rates than poor care.

Yet penalties can cost institutions up to 3% of Medicare payments a year, despite criticism that hospitals caring for the poor need more resources, not less. Just this week, Medicare fined 2300 instiutions. Research in JAMA and elsewhere has found that HRRP creates incentives for hospitals to deny readmission to patients for fear of being penalized, leading to higher HF mortality for some groups.

References

1. Greene SJ, Aliyev N, Almani MU, Ullah MQ, Fonarow GC, Khan MS. Household income and trends in 30-day readmission for patients with heart failure. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Abstract SA2124.
2. Jeon D, Ma Y, Thakkar A, Durstenfeld MS, Hsue P. Neighborhood socioeconomic status and heart failure or all-cause readmission within a safety-net system. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Abstract SA2127.