Two decades ago, “To Err is Human” exposed egregious shortcomings in the quality and safety of U.S. medical care; its sequel, “Crossing the Quality Chasm,” spurred an unprecedented stakeholder response.
What followed was a veritable explosion of quality and safety measurement and reporting, with the Centers for Medicare & Medicaid Services (CMS) as the movement’s de facto epicenter; and, inevitably, provider performance on quality measures was tied to financial incentives and penalties.
Recently, one CMS quality incentive program has come under fire.
The Hospital Readmissions Reduction Program (HRRP) — often cited as a success story for value-based payment — was designed to reduce preventable hospital readmissions among Medicare beneficiaries by penalizing hospitals with higher-than-anticipated 30-day risk-adjusted readmission rates for targeted conditions — i.e., acute myocardial infarction, heart failure, and pneumonia.
Although a number of studies have documented a decline in readmission rates following the establishment of the HRRP, recent reports raise the question of whether this program has actually improved care.
- A November 2017 study of more than 115,000 Medicare beneficiaries who were discharged after hospitalizations for heart failure reported that, although there was a reduction in 30-day and 1-year readmissions, there was an increase in 30-day and 1-year mortality. This led the authors to question whether incentives to reduce readmissions might encourage inappropriate care strategies that, in turn, adversely affect patient outcomes.
- A January 2019 study looking at Medicare data pre- and post-implementation of the HRRP (more than 7 million admissions) concluded that the program caused or contributed to a statistically significant increase in mortality among patients with heart failure and pneumonia — two of the three conditions initially covered under the program.
While speculating that hospitals may have employed inappropriate care strategies in order to avoid penalties, the authors recognized that other factors (such as changing attitudes on end-of-life care and updated electronic transaction standards) may also have influenced hospital admissions and care outcomes.
Adding fuel to the fire, the HRRP has come under intense criticism from the research community because of perceived shortcomings in the design of the program’s underlying measures and the process used to develop them.
On the cover of a recent issue of Modern Healthcare (emblazoned with, “Got a problem with CMS’ readmission measures? Blame Yale New Haven”), Maria Castellucci called into question CMS’ practice of contracting with the same small group of organizations that receive millions of dollars for measure development — a process that often results in measures that lack diversity and rigor.
Yale New Haven Health is a perennial recipient of multi-million-dollar CMS measure development contracts; one of its prominent researchers has publicly defended the HRRP program by citing positive outcomes in his own studies.
Castellucci notes that the research community is largely silent on the likely conflict of interest issues that arrangements raise.
In a related editorial, Merrill Goozner observed that it is time for the National Academies to judge whether quality and safety have really improved by performing a study that takes a holistic view of progress and brings that context to its analysis of individual programs.
My take on all this is that there are probably fundamental flaws with the HRRP and the CMS measure-designing process. With the health and safety of all Americans at stake, we can’t afford to make assumptions; we must take definitive steps to assure that someone is assessing the quality of our quality measures.