Affordable Care Act penalties pay dividends in readmissions reductions, Annals of Internal Medicine study shows

The penalties levied under the Affordable Care Act's Hospital Readmissions Reduction Program are achieving the desired result, according to a new study published in the Annals of Internal Medicine. Not only were the penalties associated with reduced readmissions rates, but the poorest performing hospitals saw the greatest reductions.

HRRP was enacted into law in 2010 and implemented in 2012 in response to the high numbers of patients who were readmitted within 30 days of their initial discharge from the hospital after treatment for several conditions -- including heart failure, pneumonia and heart attack.

While some readmissions may be unavoidable, there was evidence of wide variation in hospitals' readmission rates before the ACA, suggesting that patients admitted to certain hospitals were more likely to experience readmissions compared to others.

Researchers at Beth Israel Deaconess Medical Center, the Harvard T.H. Chan School of Public Health and Massachusetts General Hospital examined Medicare fee-for-service hospitalization data from more than 2,800 hospitals across the country between 2000 and 2013.

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Based on 30-day readmission rates after initial hospitalization for acute myocardial infarction, congestive heart failure or pneumonia, the researchers categorized hospitals into one of four groups based on the penalties they had incurred under the Hospital Readmissions Reduction Program: highest performance (0 percent penalty), average performance (greater than 0 percent but less than 0.5 percent penalty), low performance (equal to or greater than 0.5 percent but less than 0.99 percent penalty), and lowest performance (equal to or greater than 0.99 percent penalty).

"It turned out that all groups of hospitals improved to some degree," said co-senior author Francesca Dominici, PhD, professor of biostatistics and senior associate dean for research at the Harvard T.H. Chan School of Public Health, in a statement. "Notably, we found that it was the hospitals that were the lowest performers before passage of the Affordable Care Act that went on to improve the most after being penalized financially."

"For every 10,000 patients discharged per year, the worst performing hospitals -- which were penalized the most -- avoided 95 readmissions they would have had if they'd continued along their current trajectory before the implementation of the law," she said. "It's a testament to the fact that hospitals do respond to financial penalties, in particular when these penalties are also tied to publicly reported performance goals."

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Research published earlier this year in Health Affairs found that safety-net hospitals are particularly prone to high readmission rates, largely because they serve low-income patients. Yet even those hospitals have also made progress in cutting down readmissions, to a degree. In the first three years of the HRRP, safety-net hospitals reduced readmissions for heart attack by 2.86 percent, heart failure by 2.78 percent, and pneumonia by 1.77 percent. They also reduced the disparity between their readmission rates and those of other hospitals.

Around the same time, Johns Hopkins researchers found that hospitals with the highest rates of readmission were actually more likely to show better mortality scores in patients treated for heart failure, COPD and stroke, suggesting a potentially problematic relationship between the data on mortality and hospital readmissions used by the Centers for Medicare and Medicaid Services to score and reimburse hospitals.

Researcher Daniel J. Brotman, MD, said then that "using readmission rates as a measure of hospital quality is inherently problematic. High readmission rates could stem from the legitimate need to care for chronically ill patients in high-intensity settings," especially in cases of medically fragile patients who have been kept alive against the odds.

Twitter: @JELagasse