Related Experiment Video
Updated: Apr 20, 2026
Cutoff Value of Phase Angle by Bioelectrical Impedance Analysis at Admission as a Prognostic Factor in Patients with Acute Heart Failure
Published on: June 10, 2025
Indications of biased risk adjustment in the hospital readmission reduction program
Richard L Fuller1, Graham Atkinson, John S Hughes
1JKTG Foundation, Washington, District of Columbia (Dr Atkinson); and Yale University School of Medicine, New Haven, Connecticut (Dr Hughes). Mr Fuller is a payment design consultant, Schnecksville, Pennsylvania.
Insights
The Centers for Medicare and Medicaid Services (CMS) hospital readmission penalties may unfairly penalize hospitals. Inadequate risk adjustment overstates readmission rates for patients with chronic conditions and advanced age.
Area of Science:
- Health Services Research
- Healthcare Policy
- Public Health
Background:
- The Centers for Medicare and Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP) imposes financial penalties on hospitals with high readmission rates.
- Accurate risk adjustment is crucial for fairly assessing hospital performance under the HRRP.
Purpose of the Study:
- To evaluate the impact of patient chronic conditions and advanced age on readmission rates within the HRRP.
- To determine if current risk adjustment models adequately account for these patient factors.
Main Methods:
- Analysis of Medicare claims data.
- Assessment of readmission ratios for hospitals with high percentages of patients with chronic conditions and advanced age.
- Evaluation of the effect of patient demographics and comorbidities on penalty allocation.
Main Results:
- Hospitals with a high proportion of patients with chronic conditions and advanced age have overstated excess readmission ratios due to inadequate risk adjustment.
- An estimated 4.5% of heart failure, 6.2% of pneumonia, and 13.8% of acute myocardial infarction cases in high disproportionate share hospitals may face inappropriate penalties.
Conclusions:
- The current risk adjustment model for the HRRP may lead to inequitable penalties.
- Urgent independent review of the HRRP risk adjustment model is recommended to ensure fairness and alignment with program intent.
Abstract:
The Centers for Medicare and Medicaid Services hospital readmission reduction program administers substantial penalties to hospitals with excess readmissions. In our analysis of Medicare claims data, we find hospitals with the highest percentages of patients with several chronic conditions and advanced age have excess readmission ratios that are overstated because of inadequate risk adjustment. The distribution of chronic conditions and age is sufficient to cause 4.5% (heart failure), 6.2% (pneumonia), and 13.8% (acute myocardial infarction) of high disproportionate share hospitals to inappropriately receive penalties out of keeping with the intent of the hospital readmission reduction program. We believe that the risk adjustment model underlying the HRRP requires urgent independent review.
Related Concept Videos
01:23Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast,...
01:12Relative Risk
01:12Hazard Ratio
For example, in a clinical trial...
01:11Hazard Rate
01:14SBAR II: Application of SBAR
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
01:22Healthcare Associated Infections II: Preventive Measures
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...