The CMS' Hospital Readmissions Reduction Program is the policy vanguard of the transition from process to outcome measures for hospital reporting and payment.
However, one consequence of the effort has been the portrayal of safety net and some rural hospitals as delivering lower-quality care. This results in hospitals that care for the most vulnerable populations receiving the most significant payment penalties through the program—a side effect that could perpetuate disparities in access to care and health outcomes.
We believe there's another narrative. With this alternative account, differences in the economic and social characteristics of patients' communities are important contributing factors to readmissions—factors not currently included in the CMS' risk-adjustment methodology. The current system holds hospitals and other providers accountable for community-based factors such as reliable systems for nutritious food or transportation. Hospitals that serve patients with fewer community support systems can expect to have higher readmission rates because an “outcome” like readmission can be influenced by factors independent of hospitals' control.
Designing risk adjustment is high stakes because it balances the risk of unfairly penalizing safety net providers—or unfairly rewarding others—with the danger of masking or excusing real examples of poor quality. We've been among the voices calling for the inclusion of socio-demographic factors in the risk-adjusted measurement of health outcomes. Our vision is not to upend the CMS methodology, but to learn how to enrich it with data on the social determinants of health. This enrichment can take many forms—in Missouri the efforts have included measures that account for Medicaid status, poverty and risk factors attributable to patients' communities.
For socio-demographic status- adjustment proponents—most of whom are from academia or are state-level policy analysts—there's been frustration with the CMS' slow pace in recognizing the pernicious effects of these socio-economic issues on hospital readmissions. The CMS has recognized the impact of these factors on other Medicare programs, including endorsement of socio-demographic adjustments to Medicare Advantage ratings, and a guide and demonstration on readmission risk assessment for individuals and communities scoring low on socio-demographic factors. Meanwhile, with hospitals receiving enormous and potentially inappropriate penalties, the debate continues.
