The Affordable Care Act Hospital Readmissions Reduction Program (HRRP) stands as a critical initiative within the U.S. healthcare system. This Medicare program is specifically designed to encourage hospitals to elevate their standards of patient care, particularly focusing on enhancing communication and care coordination. By incentivizing improvements in discharge planning and patient engagement, HRRP aims to significantly reduce avoidable hospital readmissions, ultimately contributing to better health outcomes for individuals across the nation. This program directly supports the overarching national objective of fostering improved healthcare quality for all Americans by linking Medicare payments to the quality of care provided by hospitals.
The Legislative Basis and Objectives of HRRP
The legal framework for the Hospital Readmissions Reduction Program is established in Section 1886(q) of the Social Security Act. This legislation mandated the Secretary of the Department of Health and Human Services to implement payment reductions for subsection (d) hospitals experiencing excess readmissions, starting on October 1, 2012, which marked the beginning of fiscal year (FY) 2013. Further expanding on this, the 21st Century Cures Act instructed the Centers for Medicare & Medicaid Services (CMS) to evaluate a hospital’s performance relative to peer institutions with similar proportions of patients who are dually eligible for both Medicare and full Medicaid benefits, commencing in FY 2019. To ensure budget neutrality, the legislation stipulates that estimated payments under this peer grouping methodology (FY 2019 onwards) must equal the estimated payments under the previous non-peer grouping methodology (FY 2013 to FY 2018).
Core Measures and Conditions Targeted by HRRP
CMS utilizes specific 30-day risk-standardized unplanned readmission measures to assess hospital performance under the program. These measures are condition or procedure-specific and currently include:
- Acute Myocardial Infarction (AMI): Commonly known as a heart attack, this condition requires prompt and effective care to prevent complications and readmissions.
- Chronic Obstructive Pulmonary Disease (COPD): A progressive lung disease that necessitates ongoing management and careful discharge planning to minimize readmissions.
- Heart Failure (HF): A chronic condition where the heart doesn’t pump blood as well as it should, requiring comprehensive care and patient education to avoid readmissions.
- Pneumonia: An infection of the lungs that can be serious, especially for older adults, and necessitates effective treatment and follow-up care.
- Coronary Artery Bypass Graft (CABG) Surgery: A major surgical procedure to improve blood flow to the heart, requiring careful post-operative care and monitoring.
- Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA): These elective joint replacement surgeries require comprehensive pre- and post-operative care to ensure successful outcomes and reduce readmissions.
How Payment Reductions are Calculated and Applied
CMS calculates payment reductions for each hospital based on their performance during a rolling performance period. The payment adjustment factor serves as the mechanism for reducing hospital payments. These reductions are applied to all Medicare fee-for-service base operating diagnosis-related group payments during the fiscal year, which runs from October 1 to September 30. It’s important to note that the payment reduction is capped at a maximum of 3 percent, corresponding to a payment adjustment factor of 0.97.
Hospital-Specific Reports and Data Review Process
Annually, CMS provides confidential Hospital-Specific Reports (HSRs) to hospitals, detailing their performance under the HRRP. Hospitals are granted a 30-day review period to examine their HRRP data as presented in these HSRs. During this time, hospitals can submit inquiries regarding the calculation of their results and request corrections if they identify any calculation errors. It is crucial to understand that the Review and Correction period is strictly limited to discrepancies related to the calculation of payment reductions and component results. Hospitals cannot use this period to submit corrections to the underlying claims data or add new claims to the data extract.
Public Reporting and Data Availability
Following the Review and Correction period, CMS makes HRRP data publicly available through several channels. This data is reported in the Inpatient Prospective Payment System/Long-Term Care Hospital Prospective Payment System Final Rule HRRP Supplemental Data File, accessible on CMS.gov. Furthermore, hospital HRRP data is also published on the data catalog available at Data.cms.gov.
For individuals seeking deeper insights into the readmission measures and the program’s background, comprehensive information is readily available in the Related Links section on the CMS website. Additionally, supplemental data files from previous program years can be accessed by visiting the Archived Supplemental Data Files page.
