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Misclassification of Hospital Performance Under the Hospital Readmissions Reduction Program: Implications for
Changyu Shen1, Rishi K Wadhera1, Robert W Yeh1
1Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Importance:
The Centers for Medicare and Medicaid Services (CMS) use point estimates of 30-day risk-standardized readmission rates (RSRRs) to compare hospitals under the Hospital Readmissions Reduction Program (HRRP). An important characteristic of this measure is that it is a point estimate with a margin of error, which may affect the CMS's ability to accurately evaluate and distinguish hospital performance in the program.
Objective:
To determine the number and percentage of hospitals with a penalty status misclassified under the HRRP.
Design, Setting, And Participants:
This cross-sectional study used the bayesian deconvolution method to estimate the rate of penalty status misclassification for hospitals participating in the HRRP in fiscal year 2019, using data from the CMS Hospital Compare website that were collected between July 1, 2014, and June 30, 2017. Beneficiaries of Medicare fee-for-service coverage who were 65 years or older and hospitalized with acute myocardial infarction, heart failure, or pneumonia in hospitals with 25 or more discharges per condition were included in the data set. Data analysis occurred from November 2019 to July 2020.
Exposures:
None.
Main Outcomes And Measures:
The rate of penalty status misclassification for acute myocardial infarction, heart failure, or pneumonia under the HRRP.
Results:
The study included 1633, 2626, and 2705 hospitals for acute myocardial infarction, heart failure, and pneumonia, respectively, that participated in the HRRP in fiscal year 2019. The percentages of hospitals that should have been penalized, but were not, were 20.9% (95% CI, 16.0%-25.8%) for acute myocardial infarction, 13.5% (95% CI, 9.8%-17.2%) for heart failure, and 13.2% (95% CI, 10.3%-16.1%) for pneumonia. In contrast, the percentages of hospitals that were incorrectly penalized by the HRRP were 10.1% (95% CI, 5.8%-14.4%) for acute myocardial infarction, 10.9% (95% CI, 7.2%-14.6%) for heart failure, and 12.3% (95% CI, 9.9%-14.6%) for pneumonia.
Conclusions And Relevance:
The margin of error associated with the 30-day RSRRs resulted in the misclassification of condition-specific penalty status for up to 31% of hospitals. These findings suggest that the hospital-level 30-day RSRR measure may not reliably distinguish hospital performance in the HRRP. This has important implications for CMS value-based programs that use risk-standardized outcomes to evaluate and compare hospital performance.
Insights
The Hospital Readmissions Reduction Program (HRRP) may misclassify up to 31% of hospitals' penalty status due to margins of error in 30-day risk-standardized readmission rates (RSRRs). This impacts the Centers for Medicare and Medicaid Services' (CMS) ability to accurately evaluate hospital performance.
Area of Science:
- Health Services Research
- Health Policy Analysis
- Biostatistics
Background:
- The Centers for Medicare and Medicaid Services (CMS) utilize 30-day risk-standardized readmission rates (RSRRs) to assess hospital performance under the Hospital Readmissions Reduction Program (HRRP).
- These RSRRs are point estimates with inherent margins of error, potentially compromising the accuracy of hospital performance evaluations and comparisons.
Purpose of the Study:
- To quantify the extent of penalty status misclassification among hospitals participating in the HRRP.
- To determine the number and percentage of hospitals inaccurately penalized or not penalized under the HRRP due to statistical uncertainty.
Main Methods:
- A cross-sectional study employed a Bayesian deconvolution method to estimate penalty misclassification rates.
- Data from the CMS Hospital Compare website (July 2014-June 2017) were analyzed for fiscal year 2019 HRRP participants.
- The study focused on Medicare fee-for-service beneficiaries aged 65+ hospitalized for acute myocardial infarction, heart failure, or pneumonia.
Main Results:
- For fiscal year 2019, misclassification rates varied by condition: 20.9% of acute myocardial infarction hospitals, 13.5% of heart failure hospitals, and 13.2% of pneumonia hospitals were misclassified as not needing a penalty.
- Conversely, incorrect penalties were applied to 10.1% (acute myocardial infarction), 10.9% (heart failure), and 12.3% (pneumonia) of hospitals.
- Overall, up to 31% of hospitals experienced penalty status misclassification due to the margin of error in RSRRs.
Conclusions:
- The margin of error in 30-day RSRRs significantly impacts the accuracy of hospital penalty status determination under the HRRP.
- The current RSRR measure may not reliably differentiate hospital performance, potentially leading to inaccurate assessments.
- These findings have critical implications for CMS value-based purchasing programs that rely on risk-standardized outcomes for hospital evaluation.
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