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Abstract
The Hospital Readmissions Reduction Program (HRRP), a penalty-based pay for performance policy mandated by the 2010 Affordable Care Act, aims to improve health care quality for seniors and cut costs by avoiding readmissions but may disproportionally affect disadvantaged populations. Our study using patient-level survival analysis of data on outcomes for Medicare beneficiaries age 65 years and older who were discharged with heart failure from Pennsylvania inpatient prospective payment systems hospitals from 2010 to 2015, confirm that risk -adjusted readmissions have decreased but the likelihood of mortality has increased for some patients. NonWhite heart patients and those living in lower income areas had higher risk of readmission within 30-day and one-year of discharge. Patients living in lower income areas also had a higher risk of mortality than those in more affluent communities. Findings suggest unintended consequences and the need for policy makers and administrators to address the social determinants of health.
Introduction
Health care quality and cost have been long-standing concerns in the United States. In the landmark report Crossing the Quality Chasm (Institute of Medicine, IOM, 2001), the Committee on Quality Health Care in America (CQHA) recognized that the United States had experienced tremendous growth in technological developments and medical advances. However, while these advances had helped to increase life-expectancy, the quality of care received by Americans had not been commensurate with this growth nor with the staggering increase in the cost of health care (IOM, 2001). Thus, CQHA (IOM, 2001) made a rallying call for changing the health care system in the United States to achieve six aims of care: safety, effectiveness, patient-centeredness, efficiency, equity, and timeliness.
The passage of the Affordable Care Act in 2010 focused the attention of Centers for Medicare and Medicaid's (CMS) on quality and cost reduction, requiring CMS to further experiment with value-based performance initiatives. Section 3025 of the ACA required CMS to reduce hospital readmissions, a major driver of health care costs among Medicare beneficiaries in acute care hospitals operating under Medicare's inpatient prospective payment systems, IPPS, (CMS 2017). Effective for discharges on or after October 1, 2012 (Fiscal Year 2013), CMS had to implement the Hospital Readmissions Reduction Program (HRRP), a performance incentive program that penalizes hospitals for readmission within 30 days of discharge for...