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Impact of Expanded Patient Characteristics on Hospital Readmission Rates Used for Pay for Performance
Study Questions:
To what extent can variations in hospital readmission rates be explained by measurable patient characteristics not used by Medicare to adjust for risk of readmissions in pay-for-performance programs?
Methods:
A secondary analysis of Medicare claims for 2103-2014 admissions to hospitals with at least 200 admissions during the study period and linked US census data were used to assess clinical and social patient characteristics that are not currently used for risk adjustment in the Hospital Readmission Reduction Program (HRRP). A 20% sample of beneficiaries ≥65 years of age who had a least 1 hospitalization and were continuously enrolled in the traditional fee-for-service program during the year of admission and in the prior year. The main outcome measures were 30-day readmissions and combined 30-day readmission or mortality. Clinical and social patient characteristics were used to adjust for risk of hospital readmission rates.
Results:
Claims data for 1,169,014 index admissions among 1,003,664 unique Medicare beneficiaries (41.5% men; age 79.9 ± 8.3 years) in 2,215 hospitals were analyzed. Compared with current adjusted patient characteristics used by Medicare, adjustment for additional clinical and social characteristics reduced overall hospital variation in readmission rates by 9.6%, narrowed differences in rates between hospitals serving higher versus lower proportions of high-risk Medicare patients by 54%, and reduced expected penalties by 41% among the 10% of hospitals with the largest penalty reductions. Both clinical and social patient characteristics contributed to the reductions found, which were greater for conditions targeted by the HRRP. Adjusted social characteristics resulted in greater changes in readmission rates or death than in rates of readmission alone.
Conclusions:
Findings signify the need for building on the current patient characteristics implemented by the Centers for Medicare & Medicaid Services to assess risk for 30-day rehospitalization. Hospitals serving higher-risk patients might be financially penalized more for the types of patients served (i.e., sicker or poorer) than for the quality of care provided. Adjusting solely for within-hospital associations might allow adjustment for additional patient characteristics to mitigate unintended consequences of pay-for-performance without holding hospitals to different standards based on the patients served.
Perspective:
Although the literature is replete with studies on social determinants of health, the HRRP was implemented with a limited number of clinical conditions, and social factors were virtually absent. Research is needed that examines expanded clinical and social patient characteristics on 30-day readmissions and death. Studying additional clinical and social patient characteristics in addition to those currently used by the Centers for Medicare & Medicaid Services will help to expose factors relative to hospital readmissions and quality of care that would otherwise remain obscured.
Keywords: Quality of Health Care, Reimbursement, Incentive, Medicare, Centers for Medicare and Medicaid Services, U.S., Vulnerable Populations, Patient Readmission, Risk Adjustment, Prospective Payment System, Population Characteristics
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