Readmissions Program Has Unintended Consequences

The federal Hospital Readmission Reduction Program, introduced a few years ago by CMS, was designed to urge hospitals to reduce their readmission rates of Medicare patients by penalizing them if they didn’t achieve results. But a new study has raised a red flag.

An examination of the program’s efficacy, conducted by researchers at UCLA and Harvard, discovered that while the program drove down readmission rates of patients hospitalized with heart failure, it also impacted mortality rates. The program, study authors reported, was associated with more deaths among heart failure patients.

The findings were published in November 2017 in JAMA Cardiology, in an article titled “Association of the Hospital Readmissions Reduction Program Implementation with Readmission and Mortality Outcomes in Heart Failure.” The study asked the question: What is the association of the hospital readmissions reduction program with temporal trends in readmission and mortality rates among fee-for-service Medicare beneficiaries hospitalized with heart failure?

In the observational study of 115,245 fee-for-service Medicare beneficiaries hospitalized with heart failure at 416 sites across the United States, implementation of the CMS program was associated with a subsequent decrease in 30-day and 1-year risk-adjusted readmissions, but an increase in 30-day and 1-year risk-adjusted mortality.

These findings support the possibility that the program has had the unintended consequence of increased mortality in patients who had been hospitalized with heart failure.

The authors note that their findings should spur reconsideration of whether patients with heart failure should be encouraged to stay out of the hospital.

Joseph E. Cruz, PharmD, BCPS, Clinical Assistant Professor at Rutgers University in New Jersey, said that since this was an observational study, there is no way to assess whether a causal link exists between the implementation of the readmissions reduction program and an increased mortality rate.

“The authors suggest that changes in patient disease severity in relation to need for hospitalization over time could possibly explain the findings of increased mortality. The corollary decline in readmission rates during the same time period though may have been due to practices that manipulate admission timing and care type designation in order to avoid financial penalties associated with the Hospital Readmissions Reduction Program,” Cruz said.

He added that pharmacist assistance in providing appropriate patient follow-up will be key in ensuring that all patients get their needed care.

“Many hospitals have begun to incorporate pharmacists into transitions-of-care services that directly target patients with chronic disease states, such as heart failure, with medication discharge counseling and 48-hour follow-up phone calls postdischarge are just some examples of ways that pharmacists are currently being utilized.”

Cruz, who was not involved in the JAMA Cardiology study, noted that pharmacists in the community can also play a role in monitoring adherence and improving patient access to medications by guiding them through the enrollment process of patient assistance programs.