NURS 6050 Week 7 Policy Outcome Evaluation Example

Evaluating the Hospital Readmissions Reduction Program: What the Evidence Shows About Readmissions, Mortality, and Equity

Student Name

College of Nursing, Walden University

NURS 6050: Policy and Advocacy for Improving Population Health

Instructor Name

Month Day, Year

Evaluating the Hospital Readmissions Reduction Program: What the Evidence Shows About Readmissions, Mortality, and Equity

Program Description

The Hospital Readmissions Reduction Program was created by section 3025 of the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) and began reducing Medicare payments in federal fiscal year 2013. It applies to acute care hospitals paid under Medicare's inpatient prospective payment system. For each of several target conditions, initially acute myocardial infarction, heart failure, and pneumonia, later joined by chronic obstructive pulmonary disease, elective hip and knee replacement, and coronary artery bypass surgery, the Centers for Medicare & Medicaid Services calculates each hospital's risk-adjusted rate of unplanned readmissions within 30 days of discharge. Hospitals whose rates exceed what would be expected receive a reduction in their Medicare base payments for all admissions in the following year, capped at 3 percent. The program's mechanism is financial pressure: it attaches a penalty to readmissions to motivate hospitals to improve discharge planning, transitions of care, and follow-up.

Goal

The program's intended outcome is to reduce avoidable readmissions within 30 days of discharge for the targeted conditions, and thereby to improve the quality of care transitions and lower Medicare spending.

Evaluation Framework

This evaluation uses the CDC's Framework for Program Evaluation in Public Health, which organizes evaluation into six steps: engage stakeholders, describe the program, focus the evaluation design, gather credible evidence, justify conclusions, and ensure use and share lessons learned (Centers for Disease Control and Prevention [CDC], 1999). The stakeholders here include Medicare beneficiaries, hospitals, especially safety-net hospitals, CMS, and the clinicians who carry out discharge and follow-up. The description above and the goal statement cover the first steps. The evaluation focuses on three questions: Did readmissions fall for targeted conditions? Did the decline reflect real improvement? Did the program produce unintended harms, particularly for patients and hospitals serving low-income populations? Evidence is drawn from peer-reviewed evaluations using national Medicare data. Conclusions are justified against the stated goal, and the final sections consider how the findings should be used.

Findings, Sorted by What They Prove

Evidence that readmissions fell

Readmission rates for the targeted conditions declined after the program was announced, and they declined faster than rates for conditions not targeted by the program. Zuckerman et al. (2016) found that the decline for targeted conditions was steepest in the period between the law's passage and the start of penalties, consistent with hospitals responding in anticipation, before leveling off. This supports the conclusion that the program was associated with fewer readmissions for the conditions it targeted.

Evidence questioning how much of the decline is real

Critics have raised two ways the decline could reflect measurement rather than care. First, patients returning to the hospital could be placed in observation status, which is outpatient and does not count as a readmission. Zuckerman et al. (2016) examined this directly and found that the increase in observation stays was not large enough, or concentrated enough in the hospitals that reduced readmissions, to explain the decline. Second, changes in how diagnoses were coded after 2011 increased recorded severity, which can make expected readmission rates higher and observed rates look better by comparison; some analysts argue that part of the measured improvement reflects this. These findings do not erase the decline, but they suggest its size is uncertain.

Evidence on mortality

The most serious concern is that pressure to avoid readmissions could lead hospitals to keep sick patients out of the hospital when they should be admitted. Wadhera et al. (2018) found that the program's announcement and implementation were associated with an increase in 30-day postdischarge mortality among Medicare beneficiaries hospitalized for heart failure and pneumonia, though not for acute myocardial infarction. The study was observational and cannot establish that the program caused the increase, and other analyses have reached different conclusions, but for heart failure in particular the finding is concerning enough that it must be part of any verdict.

Equity as an Outcome

In its early years, penalties fell disproportionately on hospitals that care for large numbers of low-income patients. Joynt and Jha (2013) found that large hospitals, teaching hospitals, and hospitals serving the poorest patients were more likely to be penalized. Readmission risk depends partly on factors outside the hospital's control, such as whether a patient can afford medications, has transportation to follow-up visits, or has stable housing, and the original risk adjustment did not account for social risk. The effect was to take money from hospitals with the fewest resources and the most challenging populations.

Congress responded in the 21st Century Cures Act, which directed CMS to compare hospitals with peers that serve similar proportions of patients dually eligible for Medicare and Medicaid, beginning in fiscal year 2019 (Pub. L. No. 114-255). Stratifying by dual-eligible share reduced penalties for safety-net hospitals without removing the incentive to improve. Evaluations since then suggest the change shifted penalties toward a more even distribution, although it did not address the deeper question of whether readmission is the right measure of quality for patients with high social risk (Ibrahim & Dimick, 2019).

Verdict

The Hospital Readmissions Reduction Program met its stated goal in part: readmissions for targeted conditions fell, and most of the decline does not appear to be explained by observation stays. The size of the true improvement is uncertain because of coding changes, the program penalized safety-net hospitals unfairly until Congress changed the comparison method, and a possible increase in mortality after heart failure hospitalization means the program should not be judged on readmissions alone. A fair verdict is that the program changed hospital behavior and reduced readmissions, but its design needed correction for equity, and its effect on survival requires continued monitoring before it can be called a success.

Nursing Inside the Program

Nurses do much of the work this program rewards. Discharge teaching about medications, warning signs, and diet, especially for heart failure patients, is a nursing function. Follow-up telephone calls within 48 to 72 hours of discharge, medication reconciliation, and coordination with home health are often led by nurses or nurse case managers. Advanced practice nurses staff transitional care clinics that see patients within a week of discharge. Nurses are also well placed to notice the program's risks: a nurse who sees a heart failure patient being discharged too early, or sent to observation when admission seems warranted, can raise the concern. Nursing leaders can use the evaluation evidence to argue for measures that capture both readmissions and mortality, and for resources to address the social needs that drive readmission in low-income patients.

References

Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health. MMWR Recommendations and Reports, 48(RR-11), 1-40.

Ibrahim, A. M., & Dimick, J. B. (2019). A decade later, lessons learned from the Hospital Readmissions Reduction Program. JAMA Network Open, 2(5), e194594. https://doi.org/10.1001/jamanetworkopen.2019.4594

Joynt, K. E., & Jha, A. K. (2013). Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA, 309(4), 342-343. https://doi.org/10.1001/jama.2012.94856

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010).

21st Century Cures Act, Pub. L. No. 114-255, 130 Stat. 1033 (2016).

Wadhera, R. K., Joynt Maddox, K. E., Wasfy, J. H., Haneuse, S., Shen, C., & Yeh, R. W. (2018). Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA, 320(24), 2542-2552. https://doi.org/10.1001/jama.2018.19232

Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine, 374(16), 1543-1551. https://doi.org/10.1056/NEJMsa1513024