New in FY 2013: Perform to increase payments

The US Centers for Medicare & Medicaid Services have implemented national value-based programs that incentivize hospitals to deliver better cardiovascular care. However, it is unclear how hospitals recognized for high-quality cardiovascular care by American Heart Association (AHA) and American College of Cardiology (ACC) national quality improvement initiatives (termed award hospitals) have performed under value-based programs. To determine if hospitals that received awards for high-quality cardiovascular care from the AHA/ACC were less likely to be penalized under the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based Purchasing Program (VBP) compared with other hospitals. This national cross-sectional study included data from short-term acute care hospitals in the United States that were participating in the HRRP or VBP in fiscal year 2018. Recognition awards for high-quality care from the AHA's Get With The Guidelines-Heart Failure and ACC's Chest Pain-MI (myocardial infarction) Registry national quality improvement initiatives. Proportion of hospitals that received a financial penalty or financial reward under the HRRP or VBP, median payment adjustments, and hospital-level 30-day mortality rates. This study included 3175 hospitals participating in the HRRP and 2781 hospitals participating in the VBP in fiscal year 2018. Under the HRRP, a higher proportion of award hospitals received financial penalties compared with other hospitals (419 [85.5%] vs 2112 [78.7%]; P < .001), although payment reductions were similar (median, 0.39% [interquartile range (IQR), 0.08%-0.84%] vs 0.33% [IQR, 0.03%-0.89%]; P = .17). Under the VBP, a higher proportion of award hospitals received penalties compared with other hospitals (250 [51.7%] vs 950 [41.4%]; P < .001), and fewer award hospitals received financial rewards (234 [48.4%] vs 1347 [58.6%]; P < .001). Median payment reductions were higher for award hospitals than other hospitals (0.01% [IQR, 0.00%-0.38%] vs 0.0% [IQR, 0.00%-0.28%]; P < .001), and median payment increases were lower (0.0% [IQR, 0.00%-0.34%] vs 0.13% [IQR, 0.00%-0.60%]; P < .001). Thirty-day mortality at award hospitals was similar (acute myocardial infarction, 13.2% vs 13.2%; P = .76) or slightly lower (heart failure, 11.3% vs 11.7%; P = .001) compared with other hospitals. Hospitals that received awards for high-quality cardiovascular care from the AHA/ACC were more likely to be penalized and less likely to be financially rewarded by federal value-based programs. These findings highlight the potential need to standardize measurement of cardiovascular care quality.

Transitions of care during a hospitalization, including admission, transfers between units, and discharge are critical processes for medication safety and areas where pharmacy can contribute. Medication discrepancies have a significant impact on patient outcomes and both The Joint Commission (TJC) and the American Society of Health-System Pharmacists (ASHP) have recognized the importance of medication reconciliation in preventing these discrepancies. In 2005, The Joint Commission made medication reconciliation a component of one of its Hospital National Patient Safety Goals (NPSG.08.01.01).1 Implementation challenges resulted in its suspension in 2009 and 2010 for revision.1 A modified goal was released in 2011 (NPSG.03.06.01) after a comprehensive review of published literature and available data. Official scoring of the goal started in July 2011.12The Joint Commission definition of medication reconciliation process requires a "clinician" compare "the medications a patient should be using (and actually is using) with newly ordered medications" and "resolves any discrepancies."2 The Joint Commission has recognized the organizational and clinical difficulties associated with the medication reconciliation process and has accepted a "good faith effort" to collect medication information as meeting the intent of the requirement. NPSG.03.06.01 aims to reduce adverse patient outcomes due to medication discrepancies by focusing on specific "risk points," including transitions of care, patient education, and effective communication between providers.2ASHP has stated that they believe implementation of an effective process for medication reconciliation would support safe medication use by patients.1 ASHP recently published a statement on medication reconciliation to summarize pharmacists' responsibilities and accountabilities in medication reconciliation practices.1 The statement encouraged all hospitals and health-systems to collaborate and create organized, multidisciplinary medication reconciliation programs, which promote continuity of patient care. ASHP believes pharmacists are uniquely qualified to lead these interdisciplinary efforts and should assume primary roles in the development of the primary components. ASHP specifically addressed five fundamental functions of medication reconciliation in which pharmacists can have an impact which are listed in table 1.In 2006, TJC released a sentinel event report on preventing medication errors. In their database of more than 350 errors, which resulted in serious harm or death, they reported 63% were partially due to communication breakdown and half of these could have been prevented with medication reconciliation.3 Cornish et al. found that 53.6% of patients enrolled in their study had a least one unintended discrepancy at hospital admission, and approximately 38% of these errors had the potential to cause moderate to severe discomfort or clinical deterioration.4 Medication reconciliation performed by pharmacists has demonstrated reduction in the frequency and severity of hospital medication errors potentially resulting in patient harm.56Based on the substantial contributions of pharmacists reconciling patient's medications, we designed and completed a pilot study at our own institution to determine the impact and feasibility of discharge medication reconciliation and patient medication education.This was a prospective, single-center, interventional study piloted on two inpatient behavioral health units at the University of Minnesota Medical Center, Fairview (UMMC, Fairview). UMMC, Fairview has 11 inpatient behavioral health units with approximately 210 inpatient beds. The average daily census for these 11 behavioral health units ranges from 165–185 patients. The study was submitted and approved by the University of Minnesota Institutional Review Board.This pilot study integrated a pharmacist into what is primarily a nurse-driven discharge process at our institution. The nursing staff is responsible for reviewing the patient's medications, requesting any home medications that may have been kept in security during the patient's hospitalization, and ensuring that any newly prescribed medications were received from our discharge pharmacy. They also review the discharge summary with the patient and provide necessary education prior to the patient's discharge.During this pilot, the study pharmacist would now be responsible for performing a chart and physical medication reconciliation upon the completion of discharge orders from the physician. The chart medication reconciliation consisted of reviewing the medication summary completed by the physician in the patient's electronic medical record (EMR). The physical medication reconciliation consisted of the pharmacist reviewing, with the actual medication bottles in hand, the patient's home medications the patient had brought with them upon admission and verifying the correct medications were received from our discharge pharmacy. The pharmacist then provided one-on-one counseling to the patient on their medication regimen. Any identified discrepancies were discussed with the medical team and changes were made by the prescribing physician. We also conducted a follow-up phone survey to measure patients' satisfaction with this service.Inclusion criteria were any patient at least 18 years of age and being discharged with at least one medication from the two pre-specified inpatient behavioral health units. The two units were both adult units with primary admission diagnoses of psychosis or mood disorders. Exclusion criteria included any patient under the age of 18 years and non-English speaking patients due to the lack of interpreter services available for the follow-up phone call. Patients under court commitment were also excluded from this study. All patients provided informed consent to participate in this study and had the option to withdraw at any time.The primary outcomes evaluated throughout this study were impact data and feasibility data. The impact of this service was evaluated by recording both the number and types of interventions identified through the discharge medication reconciliation process. An intervention was defined as any time the study pharmacist identified an actual error on the patient's discharge summary (e.g., unnecessary therapy, insufficient dose/duration) or assisted in resolving a potential error upon patient discharge (e.g., identifying and alerting the physician about the need for follow-up labs, assisting with obtaining a prior authorization). Interventions were categorized into 9 different groups which are listed in table 2.In order to evaluate the feasibility of the pharmacist-run service, the time needed to conduct each stage in the process was recorded, including medication reconciliation, communicating with providers, and then providing one-on-one counseling with the patient.Twenty-four patients provided informed consent to participate in the study; however, three of the 24 patients were not able to be included in the process due to time constraints. Of the 21 patients included in the medication reconciliation process, 12 patients (57%) required at least one intervention. Throughout the study, a total of 192 medications were reconciled and 45 interventions were identified. The number of medications on the discharge summary, per patient, ranged from 2 to 18, with a mean of 9.14 medications per patient. The number of interventions per patient ranged from 0 to 7, with mean of 2.14 interventions per patient and a median of 2 interventions per patient.The most common intervention identified in this study was unnecessary therapy, which included problems such as duplicate medication orders and re-starting medications meant to be discontinued upon discharge. Six medication discrepancies fell into the "other" category and included interventions such as: helped obtain a prior authorization, suggested a medication change upon discharge due to patient's insurance coverage, and assisted with the delivery of a medication to the patient care unit. See Figure 1 for details.The need for an intervention was most frequently identified during the chart medication reconciliation (62%), but interventions were also identified during patient counseling (18%), physical medication reconciliation (11%), and by provider request (9%).In terms of feasibility, the mean amount of time to complete the entire process per patient was 57.1 minutes. The mean times for each step were 20.2 minutes, 20.4 minutes, and 16.5 minutes for the medication reconciliation, provider communication, and patient education, respectively.A follow-up phone call satisfaction survey was also conducted. Only six patients were included in this part of the study, due to loss of follow-up with the remaining patients. Patients were called within 10 days of discharge and asked three short questions, including: (1) "Was the education helpful?" (2) "Did you gain a better understanding of your medications?" and (3) "Were you satisfied with this service?" The mean scores on a scale of 1–5 (with a score of 5 being the best/most helpful) were 4.25, 4, and 4.17 respectively. Patients were also able to give feedback on the service and offer suggestions. One common theme was that the communication and education piece was helpful and many would like to see even more, including more one-on-one medication education, during their hospitalization and additional medication education after discharge.This study demonstrated pharmacist-mediated medication reconciliation at discharge from an inpatient behavioral health unit could potentially have a significant impact on decreasing medication discrepancies and improve patient outcomes. Of the 192 medications that were reconciled through this process, the study pharmacist was able to make 45 interventions. Although many of these interventions were minor in significance, it is important to consider the various levels of health literacy of patients and take this into consideration when reviewing discharge summaries and educating the patient. Additionally, other studies have evaluated the potential clinical impact of medication reconciliation errors. One meta-analysis reported a range of 11%–59% of medication history errors that were deemed clinically significant in the studies included.7During our study, there were also interventions that may have led to readmission if not addressed prior to discharge. One example included a patient who was a new start to clozapine during their hospitalization. Follow-up care, including weekly white blood cell (WBC) and absolute neutrophil count (ANC) lab draws, had not been established for the patient. The study pharmacist communicated with the patient's psychiatry resident and the social worker to arrange another set of labs prior to the patient's discharge. The pharmacist also assisted in arranging for the patient to have labs drawn at an outside facility a week after discharge. There were also two examples of patients who would have inadvertently been discharged on their prior to admission medication dosage rather than the new increased dosage prescribed during their hospitalization.Our results were very similar to previous studies evaluating medication discrepancies at discharge. Wong et al. found that 41.3% of patients had at least one actual unintended medication discrepancy at discharge from their general internal medicine unit.8Musgrave et al. conducted a study in solid organ transplant patients and found that pharmacists identified 119 medication errors made upon discharge through pharmacist-mediated medication reconciliation, which was approximately 1.9 errors per patient.5 Our study contributes to the continued research that pharmacists can provide a valuable service to patients and is unique in that we specifically focused on mental health patients.In addition to potentially improving patient outcomes, the service was also well received by the medical staff on the selected two units. Having a pharmacist performing medication reconciliation and providing patient education freed up nursing staff to focus on other responsibilities. There was also positive feedback from the psychiatry residents on the units.While the service demonstrated great potential in terms of outcomes, the feasibility findings may limit the overall implementation of this service on all 11 inpatient behavioral health units at this time. The average time to complete the process per patient was close to an hour and with an average daily census of 165–185 patients and the potential for as many as 15–20 discharges per day it would be difficult to fully implement this service without other process improvements. One of the largest challenges facing the implementation of this service is the uncertainty of discharge date and time in this patient population. A potential process improvement to minimize this problem is to schedule discharge planning meetings, so the discharge pharmacist can work with the interdisciplinary team and plan ahead as necessary to help with a smoother process.Another process improvement that would vastly increase the feasibility of pharmacist-mediated discharge medication reconciliation and discharge counseling is to implement pharmacist-mediated admission medication reconciliation. Currently, our institution is in the process of implementing pharmacist-mediated medication reconciliation at admission but at the time of this study it was not yet fully implemented hospital wide. Many interventions upon discharge medication reconciliation could have been identified during admission, such as omitted home medications or duplicate medication orders.Finally, one major change that occurred after this study ended, that would have a major impact on the number of interventions identified, was an electronic medical record (EMR) upgrade which allowed more changes to be made to the discharge summary. During the study, it was identified that due to EMR constraints, it was difficult to completely delete medications from the discharge summary, which lead to many examples of duplicate orders on the patient's medication list.While TJC does not currently specify beyond a "clinician" providing medication reconciliation, we feel pharmacists are uniquely qualified to provide this service, both on admission and discharge, given our educational background and specialized training. Medications are our primary area of concern, whereas other health professionals have a variety of other responsibilities associated with both admissions and discharges. Shifting the task of medication reconciliation to a pharmacist would free up other health care professionals to focus on other critical components of patient care. We also feel that this pilot study follows the recommendations of ASHP for involvement in medication reconciliation. We will continue to strive for pharmacy involvement in aspects of medication safety during transitions of care.

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

APhA advances provider status initiative

In recent years, public reporting, targeted financial penalties, and incentives to develop alternative payment models that include the assumption of financial risk have compelled hospitals to focus on reducing readmission rates for high-cost conditions such as heart failure (HF). When older patients with multiple medical conditions including HF are discharged from the hospital, they are vulnerable to adverse events, which may result in recurrent hospitalization (the post-hospital syndrome).1 In theory, providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. Within the United States, home health care (HHC) referrals after acute care hospitalization increased by 65% to 3.7 million between 2001 and 2012.2,3 Patients discharged from US hospitals with a primary diagnosis of HF had the highest number of HHC referrals during this time, with ≈200 000 post-acute HHC referrals in 2012.2 In addition, HHC surpassed skilled nursing facilities as the most frequently used post-acute care among Medicare beneficiaries with HF in 2012 (unpublished HCUPnet data). Such an increase in HHC use for patients with HF is likely related to multiple factors, including decreasing length of stay for patients with HF4 and more recent pressures to improve readmission rates for HF after adoption of the Affordable Care Act in 2010, which included the Hospital Readmissions Reduction Program that was implemented in 2012.5,6 Despite substantial growth in post-acute HHC referrals for patients with HF,2 it is unclear whether HHC delivered in real-world settings consistently provides high-value care. Understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care. Because most patients referred for skilled HHC are Medicare beneficiaries, Medicare eligibility and payment policies have important implications for HHC. Patients who …

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

The Medicare Hospital Readmissions Reduction Program (HRRP) and the Medicare Hospital Value-Based Purchasing Program (HVBP) were established by the 2010 Patient Protection and Affordable Care Act with the aim of incentivizing hospital inpatient care quality improvement by conditioning a portion of a hospital's reimbursement under the Medicare Inpatient Prospective Payment System on its performance, in competition with other hospitals, on select inpatient care quality metrics. Since the programs' inception, there has been an ongoing debate among scholars and policymakers as to whether safety net hospitals (SNHs), characterized by a disproportionately large caseload of indigent and otherwise socially vulnerable patients, may be at an unfair disadvantage owing to their patients' social risk profile. Accordingly, much attention has rightly been paid to the role of patient-level social risk in explaining variation in hospitals' performance under these programs. Less attention, however, has been paid to the role of antecedent contextual resources at both the hospital-level (e.g., labor, capital, and technology inputs) and area-level (e.g., features of supportive healthcare infrastructure) despite the fact that, like social risk, the adequacy of the resource context within which a hospital operates might also be associated with inpatient care quality, un-evenly distributed across hospitals, and not entirely within a hospital's control. A separate, but related, concern raised by critics of these programs has been that burdening already resource constrained hospitals (e.g., SNHs) with financial penalties could lead to or exacerbate revenue shortfalls, compelling administrators to engage in activities that are designed to alleviate the pressures imposed by the HRRP and HVBP but may nonetheless be at odds with what is in the best interest of patients and communities (e.g., reducing proportional exposure to patients who are publicly insured; cutting back on personnel; offsetting penalties with non-operating revenue that might otherwise be put toward care quality and community health initiatives). To date, the extent to which the penalties imposed by the HRRP and HVBP have had such consequences in the several years since the programs were first implemented remains unclear. The over-arching goal of my dissertation was to meaningfully contribute to ongoing discourse among scholars and policymakers regarding the experience of hospitals generally and SNHs in particular under the HRRP and HVBP by probing both of these areas of inquiry.--Author's abstract

The hospital value-based purchasing (HVBP) program of the Centers for Medicare & Medicaid Services challenges hospitals to deliver high-quality care or face a reduction in Medicare payments. How do different organizational structures and market characteristics enable or inhibit successful transition to this new model of value-based care? To address that question, this study employs an institutional theory lens to test whether certain organizational structures and market characteristics mediate hospitals' ability to perform across HVBP domains.Data from the 2014 American Hospital Association Annual Survey Database, Area Health Resource File, the Medicare Hospital Compare Database, and the association between external environment and hospital performance are assessed through multiple regression analysis. Results indicate that hospitals that belong to a system are more likely than independent hospitals to score highly on the domains associated with the HVBP incentive arrangement. However, varying and sometimes counterintuitive market influences bring different dimensions to the HVBP program. A hospital's ability to score well in this new value arrangement may be heavily based on the organization's ability to learn from others, implement change, and apply the appropriate amount of control in various markets.

One of the most important changes to the United States health care system over the last two decades is the emergence of pay-for-performance as a way to encourage hospitals and other providers to improve quality of care. Unlike fee-for-service, these value-based purchasing programs measure aspects of quality and financially reward hospitals that are outstanding or at least improving in their care. Prior research has shown that hospitals often improve more when the marginal financial incentives are larger. However, the exact relationship between marginal financial incentives and year-over-year improvement in measures remains unclear. In this study, we use national 2015 2018 data on approximately 2,700 hospitals to estimate how hospitals respond to pay-for-performance incentives in the Hospital Value-Based Purchasing (HVBP) Program. We show that this relationship is non-linear, has strong serial correlation, is somewhat similar for safety-net hospitals as non-safety-net hospitals, and is proportional to the size of the Medicare patient population.

Background Almost 900,000 patients in the United States living with chronic obstructive pulmonary disease (COPD) require home health care each year. Pharmacists are integral members of the home health care team, especially for older adults living with COPD, because of their expertise in identifying and resolving medication therapy problems (MTPs) during transitions of care. Objective To identify, characterize, and compare the quantities and categories of MTPs in older adults living with COPD who require home health care following hospital discharge. Methods This cross-sectional study involved adults aged 65 years and older living with COPD who were discharged from an academic medical center between June 1, 2023, and November 30, 2023. MTPs were classified using two frameworks: the American Society of Health-System Pharmacists (ASHP) and the Pharmacy Quality Alliance (PQA). Results During the study period, 535 older adults were prescribed home health care, 15 of whom had a hospitalization discharge diagnosis of COPD and were screened for inclusion. Among the 13 patients eligible for inclusion, 92.3% experienced one or more MTPs. Almost 80% of the identified MTPs involved issues related to medication indication: 50% of this cross-sectional cohort were not prescribed medications when clinically indicated, and up to 40% of patients were prescribed medications without apparent indications. The ASHP framework identified more than twice the number of MTPs compared to the PQA framework. Conclusion The ASHP framework may identify more MTPs than the PQA framework in older adults living with COPD who require home health care upon discharge. Further research evaluating pharmacist interventions related to MTPs would be beneficial across diverse settings and patient populations.

Medicare's Hospital Readmission Reduction Program (HRRP) created clear financial incentives for hospitals to prevent readmissions. Although existing evidence suggests readmission rates have been declining, the direct contribution of this policy to these reductions is unclear. Furthermore, it is unknown whether HRRP has produced unintended effects, including the substitution of outpatient hospital care for readmissions. To determine the effect of HRRP in New York State on both the likelihood of being readmitted and returning to hospital emergency department (ED) care within 30 days of discharge. Difference-in-difference estimation using prepolicy and postpolicy hospital claims data and the proportion of a hospital's inpatient revenue at risk for HRRP penalization to identify policy exposure. Policy effects are estimated using multivariate logistic regressions. We find significant global reductions in readmissions in the postpolicy years, but no evidence of a differential policy effect on patients discharged from hospitals at risk for proportionally larger HRRP penalties in either postpolicy year 1 [adjusted odd ratio (AOR) =1.00, P=0.733] or 2 (AOR=1.01, P=0.315). HRRP did increase the odds of patients from hospitals facing greater financial risk having a 30-day ED visit in both postpolicy years (AOR=1.04, P=0.009 and AOR=1.07, P<0.001). Our findings suggest that while readmissions have decreased in New York State, these declines may not be directly attributable to HRRP penalties. The policy did produce significant potentially unintended effects in the form of greater postdischarge ED utilization among facilities facing proportionally larger penalties.

Background: The Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program (HRRP) has created financial penalties for hospitals with higher risk-standardized readmission rates after hospitalization for specific conditions, including congestive heart failure (CHF). Identification and risk-standardization is performed with administrative data. Both to evaluate the utility of this metric for improving quality and to inform efforts by providers to reduce readmissions, more granular clinical information about patients included in the penalty is needed. Methods: All patients who contributed to the CHF component of the HRRP penalty at our hospital between June, 2012 and December, 2013 were identified and medical records were reviewed by a physician (A.J.C.). Information extracted included index inpatient service, cause of readmission, medications, scheduled follow-up, whether echocardiogram was performed, NT pro-BNP as measured at admission and discharge, weight documented during index hospitalization, last known ejection fraction, and discharge disposition. Results: During this time period, 212 readmitted CHF patients contributed to the HRRP penalty. Of those, 31 (14.6%) were excluded due to readmission to an outside hospital. Of the remaining 181, 6 (2.8%) were excluded as the cause of index admission was not confirmed to be CHF. These patients were excluded from all analyses. Of the remaining 175 patients, 79 (45.1%) were readmitted for recurrent CHF exacerbation while 96 (54.8%) were readmitted for reasons other than CHF. Seventy (40%) patients were discharged home with visiting nurse services, 44 (25.1%) discharged home without services, and 61 (34.9%) discharged to a skilled nursing facility. Of the 114 patients discharged home, 44 (38.6%) had follow-up scheduled at the time of discharge. The median length of time between the index admission and readmission was 13 days. Among the 79 patients readmitted for CHF-related causes, 39 (49.4%) initially had been hospitalized on the cardiology service while 40 (50.6%) were hospitalized on a general medical service. Of those 79 patients, 32 (40.5%) had left ventricular systolic dysfunction (LVSD). At time of index discharge, 28 (87.5%) of patients with LVSD had been prescribed a beta blocker and 12 (37.5%) had been prescribed an ACE inhibitor or ARB. Conclusions: About half of patients who contributed to the CHF component of the HRRP penalty at our hospital were readmitted for recurrent CHF, the other half for different diagnoses. Of those who were readmitted with recurrent CHF, more than half did not have systolic dysfunction. Many of the patients with recurrent CHF due to systolic dysfunction were not initially discharged on ACE or ARB therapy, largely due to hypotension or renal dysfunction. These findings underscore the challenges of reducing preventable hospital readmission in this HRRP penalty population.

BackgroundMedicare’s Hospital Readmissions Reduction Program (HRRP), implemented beginning in 2013, seeks to incentivize Inpatient Prospective Payment System (IPPS) hospitals to reduce 30-day readmissions for selected inpatient cohorts including acute myocardial infarction, heart failure, and pneumonia. Performance-based penalties, which take the form of a percentage reduction in Medicare reimbursement for all inpatient care services, have a risk of unintended financial burden on hospitals that care for a larger proportion of Medicare patients. To examine the role of this unintended risk on 30-day readmissions, we estimated the association between the extent of their Medicare share of total hospital bed days and changes in 30-day readmissions.MethodsWe used publicly available nationwide hospital level data for 2009–2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. Using a quasi-experimental difference-in-differences approach, we compared pre- vs. post-HRRP changes in 30-day readmission rate in hospitals with high and moderate Medicare share of total hospital bed days (“Medicare bed share”) vs. low Medicare bed share hospitals.ResultsWe grouped the 1904 study hospitals into tertiles (low, moderate and high) by Medicare bed share; the average bed share in the three tertile groups was 31.2, 47.8 and 59.9%, respectively. Compared to low Medicare bed share hospitals, high bed share hospitals were more likely to be non-profit, have smaller bed size and less likely to be a teaching hospital. High bed share hospitals were more likely to be in rural and non-large-urban areas, have fewer lower income patients and have a less complex patient case-mix profile. At baseline, the average readmissions rate in the low Medicare bed share (control) hospitals was 20.0% (AMI), 24.7% (HF) and 18.4% (pneumonia). The observed pre- to post-program change in the control hospitals was − 1.35% (AMI), − 1.02% (HF) and − 0.35% (pneumonia). Difference in differences model estimates indicated no differential change in readmissions among moderate and high Medicare bed share hospitals.ConclusionsHRRP penalties were not associated with any change in readmissions rate. The CMS should consider alternative options – including working collaboratively with hospitals – to reduce readmissions.

This feature was developed from a chapter presented in PSAP 2025 Book 2 (Geriatrics). Julie B. Cooper, Pharm.D., BCPS, BCCP, is Chair and Associate Professor in the Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point, North Carolina. Reviewed by: Maria Shin, Pharm.D., BCGP, BCPS; Hailey Soni, Pharm.D., BCPS; and Ashley Heil, Pharm.D., BCPS, BCOP. Maria Shin, Pharm.D., BCGP, BCPS, is a Clinical Pharmacist Practitioner, Internal Medicine, Acute and Specialty Care Pharmacy, Robley Rex VA Medical Center, Louisville, Kentucky. Hailey Soni, Pharm.D., BCPS, is a Clinical Assistant Professor/Clinical Pharmacist, Department of Pharmacy Practice, University of Illinois Retzky College of Pharmacy, Chicago, Illinois. Ashley Heil, Pharm.D., BCPS, BCOP, is a Hematology/Oncology Clinical Pharmacist Specialist at Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota. Geriatric pharmacotherapy specialists and advanced-level clinical pharmacists providing care for older adults with common health conditions associated with aging, especially as it relates to goals of care and end-of-life care considerations. Consultancies: Maria Shin (ASHP). Grants: Julie B. Cooper (American Association of Colleges of Pharmacy, American Society of Health-System Pharmacists). Honoraria: Maria Shin (Sullivan University College of Pharmacy). Stock Ownership: Hailey Soni (Abbott Laboratories). Nothing to disclose: Ashley Heil. The American College of Clinical Pharmacy is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of CPE. Learners may earn up to a total 4.0 CPE hours by submitting the required posttests for ACPE and BCPS recertification credit. Posttest access can be purchased by ACCP members for $29.95 and by non-members for $39.95 at https://www.accp.com/store/product.aspx?mode=series&sc=PSAP_JACCP. One or both posttests may be submitted for credit. To be eligible for BCPS recertification credit, posttests must be submitted by September 8, 2026, and achieve the predetermined passing score. To be eligible for ACPE CPE, posttests must be submitted by March 8, 2029, and achieve a score of 50% or higher. Julie B. Cooper: writing – original draft, writing – review and editing. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review