CMS' readmission measure used in its Hospital Readmissions Reduction Program has been widely criticized for failing to reflect true quality and unfairly penalizing certain types of hospitals.
In its final rule for the fiscal year 2014 Hospital Inpatient Prospective Payment System, CMS responded to comments on the readmission measure. Here are six common critiques of the measure and excerpts of CMS' response from the IPPS rule:
1. Mortality rates
Comment: A commenter suggested CMS analyze the impact of the Readmissions Reduction Program on mortality rates.
CMS response: "We believe that there does not appear to be a meaningful correlation between hospital risk-standardized mortality rates and readmission rates."
2. Observation status
Comment: A commenter suggested CMS monitor unintended consequences of the program, "such as avoiding admissions for difficult patients or placing more patients in observations to avoid readmissions."
CMS response: "We are especially cognizant of those areas of concern raised by stakeholders, including inappropriate shifting of care, increased patient morbidity and mortality and increases in the use of observation services to avoid hospital readmissions. We remain committed to quickly addressing these areas, as well as any other unintended consequences that may arise as the Hospital Readmissions Reduction Program progresses."
3. Planned readmissions
Comment: Stakeholders commented that planned readmissions do not usually reflect poor quality of care.
CMS response: CMS developed an expanded planned readmission algorithm that excludes more planned readmissions from the penalty calculation.
4. Rural areas
Comment: One commenter suggested the readmission measure be risk-adjusted for hospitals in rural areas, which may cause higher readmission rates than those at hospitals in more populated areas.
CMS response: "Our most recent analyses […] examined hospital readmission rates for different hospital referral regions and did not find a relationship between rural referral regions and increased readmission rates."
5. Socioeconomic status
Comment: While some commenters opposed a risk adjustment for socioeconomic status, others called for CMS to adjust for this and other factors outside of providers' immediate control that may negatively affect some hospitals more than others.
CMS response: "We routinely monitor the impact of socioeconomic status on hospitals' results and have consistently found that hospitals that care for large proportions of patients of low socioeconomic status are capable of performing well on our measures." CMS also noted that adjusting rates for socioeconomic status has only a minimal effect on hospitals' rates and that CMS does not want to "minimize incentives to improve the outcomes of disadvantaged populations."
6. Unrelated readmissions
Comment: Some commenters said the planned readmission algorithm does not account for unrelated readmissions. Others suggested unrelated admissions should be excluded from the payment adjustment.
CMS response: CMS noted that it does account for certain unrelated readmissions and that it continues to revise them through its expansion of planned readmissions. "Regarding other types of unrelated readmissions, we currently do not seek to differentiate between related and unrelated readmissions because readmissions not directly related to the index condition may still be a result of the care received during the index hospitalization."
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