The expansion of the CMS' long-standing readmissions penalty program to hip and knee replacement procedures didn't lead to significant reductions in 30-day return rates to hospitals, a new study finds.
While readmission rates have declined for total hip and knee replacement surgeries, the most dramatic improvements happened before providers even knew the procedures were included in the Hospital Readmissions Reduction Program, according to the analysis published Monday in Health Affairs.
The program was announced in 2010 with the passage of the Affordable Care Act, but the CMS didn't notify hospitals that hip and knee replacement procedures would be included until August 2013. Even so, the study found that reductions in 30-day readmission rates for the surgeries nearly doubled from 2010 to 2013 but then returned to pre-2010 reduction rates after the program was expanded to those procedures.
The CMS "may have squeezed all of the juice that was possible out of these penalties," said Dr. Karan Chhabra, lead author of the study and a fellow at the Institute for Healthcare Policy and Innovation at the University of Michigan.
The findings are in line with those of other analysts, who found most of the improvement in readmission rates actually happened in the time leading up to the start of the program as hospitals made organization-wide performance improvement changes to avoid a penalty. The program dings hospitals for up to 3% of their Medicare payments.
In a statement, a CMS spokeswoman echoed previous comments from the agency and said it throughly reviews "relevant literature to inform future actions" to the program. She added, "Significant reductions in readmissions have been made over time, which CMS believes is due in part to the program linking Medicare reimbursement for hospitals to their performance on readmission rates."
This study is the latest that questions the impact of the program and possible harmful consequences for patients. Given this growing body of research, Chhabra said it may be time to retire the program.
"If the benefits are starting to shrink, but the harms are persisting … this program may be at the end of its life," he said.
Chhabra suggested bundled-payment programs as an alternative. The readmission program has successfully encouraged hospitals to pay attention to care coordination to avoid a penalty. That kind of focus shouldn't be lost, but Chhabra said bundled payments take a more holistic approach to patient care.
"Bundled-payment programs do discourage unnecessary readmissions but in the setting of a broader 90-day episode," he said.
In addition to the readmission rates, the study also found that the average Medicare cost of hip and knee replacements dropped by $3,000 from 2008 to 2016. Although that's a positive sign, Chhabra said the savings likely weren't the result of the readmissions program. Instead, there has been a focus on discharging patients to home instead of to post-acute care, which would explain the change.