Written by Kim Furlow, communications manager for the Institute for Public Health
The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with high readmission rates however, a few years ago, the program was changed so that hospitals would only be compared against other hospitals with similarly impoverished patients.
A new study led by researcher, Sukruth A. Shashikumar and subsequent research article co-authored by Karen Joynt Maddox, co-director of the Center for Health Economics and Policy, looks at the effect of this policy change on hospitals that serve a high proportion of minority patients. This research fits into Shashikumar’s broader assessment of the intersection of policy and health equity.
HRRP is one of Medicare’s “value-based payment” programs that is supposed to link the payments that hospitals receive to the quality of care that they deliver to their patients. Shashikumar points to a major flaw in the original program and, subsequently, one of the reasons that it became very unpopular among health care providers. The HRRP formerly compared readmission rates at all hospitals to every other hospital. The program did not account for the fact that different hospitals may care for patient populations that have higher risks of readmission.
“That was like comparing apples to oranges,” says Shashikumar. In other words, hospitals treating affluent patients were compared with those serving more impoverished patients. The latter are at risk for higher readmission rates due to factors out of their control such as decreased physical and financial access to clinics/pharmacies; housing instability; low education/job opportunities/income; unstable insurance; etc., all of which increase the risk of poor outcomes, including readmission to the hospital. The result of this earlier program was that the HRRP disproportionately penalized high-poverty hospitals for “worse quality” care due to their “high” readmission rates, says Shashikumar.
In 2019, congress changed the HRRP program to compare apples to apples: Hospitals with dually enrolled Medicare and Medicaid patients are now compared only to similar hospitals. The study looks at the impact of this policy change over the past three years among safety-net hospitals, rural hospitals, and hospitals disproportionately serving Black and Hispanic/Latino patients. These hospitals are shown to operate on lower budgets and are therefore more sensitive to penalties.
“We found that this policy change was associated with a lessening of penalties to hospitals serving several important communities and patients who are rural, disabled, from minority backgrounds, dependent on safety-net services, and/or live in socioeconomically disadvantaged neighborhoods,” says Shashikumar. “I also think this [study] adds to the growing literature urging policymakers to consider patients’ social factors (e.g., poverty, functional status, systemic racism, etc.) when evaluating hospital performance.
Patients don’t exist in a vacuum, and their clinical outcomes are influenced heavily by their lives, social circumstances, and communities – all of which are important and out of hospitals’ control. These social determinants of health must be accounted for when judging hospital quality outcomes and determining payment under value-based programs.”