Hospital participation in voluntary value-based reforms is associated with greater readmission reductions under Medicare’s Hospital Readmission Reduction Program (HRRP), according to a retrospective study.

“We had no real expectations that hospitals’ participation in voluntary reforms would be associated with additional reductions in readmissions,” Dr. Andrew M. Ryan from the University of Michigan School of Public Health in Ann Arbor told Reuters Health by email. “We thought that it was just as likely that hospital participation in meaningful use, accountable care organization (ACO) programs, or the Bundled Payment for Care Initiative (BPCI) may be distracting to hospitals, limiting readmission reduction,” he said.

The Centers for Medicare and Medicaid Services (CMS) aimed these programs at hospitals, with a goal of improving quality and reducing spending growth – but the combined effects of these simultaneous reforms are unknown.

Dr. Ryan and colleagues used national data from Hospital Compare on hospital readmissions for 2,837 hospitals from 2008 to 2015 to investigate whether participation in these three value-based reforms was associated with greater improvement in Medicare’s HRRP. Although no hospitals were participating in these programs in 2010, by 2015, only 56 hospitals were not participating in at least one of them, according to the April 10th JAMA Internal Medicine online report.

Participation rates were highest for meaningful use programs (97.5%), followed by ACO programs (18.3%) and BPCI (11.9%). After initiation of the HRRP, 30-day readmission rates declined by 1.46 percentage points for acute myocardial infarction (AMI), by 2.13 percentage points for heart failure, and by 1.32 percentage points for pneumonia, the three incentivized diagnoses examined in this study.

Participation in meaningful use programs alone was associated with additional readmission rate reductions of 0.78 percentage points for AMI, 0.97 percentage points for heart failure, and 0.56 percentage points for pneumonia. Participation in ACO programs alone brought additional reductions of 0.94 percentage points for AMI, 0.83 percentage points for heart failure, and 0.59 percentage points for pneumonia.

Greater participation translated into greater readmission rate reductions, so that participation in all three programs was associated with additional reductions in 30-day readmission rates of 1.27 percentage points for AMI, 1.64 percentage points for heart failure, and 1.05 percentage points for pneumonia, compared with hospitals that participated in no reforms.

“Our findings suggest that the different reforms initiated by CMS may be self-reinforcing,” Dr. Ryan said. “This may enhance the spending reductions associated with any one program.”
“We may reach a point where CMS is trying too many things to improve value,” he speculated. “But it doesn’t seem like we’ve reached that point yet.”

Dr. Karen E. Joynt from Brigham and Women’s Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts told Reuters Health by email, “The findings suggest that hospitals are responding to financial incentives, at least to some degree. However, after an initial decline in readmissions, the rate of improvement really leveled off in 2014-2015. It’s not clear why that should happen, given that penalties were actively being assessed, and in fact getting larger, during that time frame. That was also when the most hospitals were participating in ACOs and/or BPCI.”

“As ACOs, BPCI, and other programs continue to expand, and as value-based purchasing (VBP) programs in the outpatient and post-acute settings ramp up, it will be important to continue to look at the data and determine whether the decline in readmission rates restarts,” she said.