How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions?: an Analysis from 2007 to 2014 in Five US States

Abstract

BACKGROUND: Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen. OBJECTIVE: To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals. DESIGN: Repeated cross-sectional analysis, stratified by safety-net status. SUBJECTS: 1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR. MAIN MEASURES: Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014. KEY RESULTS: Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P < 0.05). These trends continued following the passage of HRRP. CONCLUSIONS: Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safetynet hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.

Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric

“…24 They may have a higher proportion of patients from disadvantaged groups, who are more likely to be discharged to an institution rather than to home 25 and who have higher readmission rates. 26 Safety-net hospitals may have a disproportionate number of patients with social and cultural challenges such as poor language skills, low health literacy, or lack of access to food, housing, and transportation. 27,28 To address the inequity of disproportionately penalizing hospitals that provide care to the most vulnerable patients, the 21st Century Cures Act of 2016 requires CMS to benchmark each hospital's performance compared with hospitals with similar characteristics, rather than all other hospitals.…”

Trends in 30-Day Readmission for Medicaid and Privately Insured Pediatric Patients: 2010–2017

“…Researchers of other studies in adult populations have reported mixed results for racial and socioeconomic disparities in readmission rates over time. [24][25][26][27] Over half of pediatric admissions in the United States are covered by Medicaid, and this number has grown substantially under the Affordable Care Act and the Children's Health Insurance Program. 16,17 As such, this population represents an important target for readmission reduction efforts with the potential to significantly cut health care expenditures.…”

Combined impact of Medicare’s hospital pay for performance programs on quality and safety outcomes is mixed

“…Evidence on the intended impacts of these programs has been mixed. Early research suggested that introduction of the HRRP was associated with a decline in targeted readmissions [ 3 ] and larger HRRP penalties may be associated with larger improvements [ 3 , 4 ]. More recent studies, however, suggest that reductions in readmissions attributed to HRRP may be overstated due to concurrent changes in electronic claim standards [ 5 ].…”