Medicare's hospital readmissions reduction program and the rise in observation stays

Objective: To evaluate whether Medicare's Hospital Readmissions Reduction Pro-gram (HRRP) is associated with increased observation stay use. Data Sources and Study Setting: A nationally representative sample of fee-for-service Medicare claims, January 2009-September 2016. Study Design: Using a difference-in-difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2-year post-implementation period, with specific dates defined by HRRP policies. Data Collection/Extraction Methods: We derived a 20% random sample of all hospitalizations for beneficiaries continuously enrolled for 12 months before hospitalization (N = 7,162,189). Principal Findings: Observation stays increased similarly for the initial HRRP target and nontarget conditions in the intervening period (0.01% points per month [95% CI -0.01, 0.3]). Post-implementation, observation stays increased significantly more for target versus nontarget conditions, but the difference is quite small (0.02% points per month [95% CI 0.002,0.04]). Results for the COPD analysis were statistically insignificant in both policy periods. Conclusions: The increase in observation stays is likely due to other factors, including audit activity and clinical advances. KEYWORDS difference-in-differences, hospital readmissions reduction program, inpatient, Medicare, observation stays, recovery audit contractors What is known on this topic * Observation stays have increased significantly over the last 15 years. * Observation stays are excluded from the numerator and denominator of readmissions measures. * Medicare's Hospital Readmissions Reduction Program (HRRP) may incentivize hospitals to substitute observation stays for inpatient readmissions, although evidence of this is mixed. What this study adds * Ours is the first study to examine how hospitals may have responded to the HRRP by using observation stays in lieu of both index admissions and readmissions. * Using quasi-experimental methods, we find that the HRRP was not meaningfully associated with differential increases in the use of observation stays for target versus nontarget conditions. * The increase in observation stays is more likely the result of advances in clinical care and hospitals taking steps to avoid payment audits.
1 | INTRODUCTION Medicare's Hospital Readmissions Reduction Program (HRRP) has been controversial since its announcement. One ongoing concern is whether the HRRP incentivizes hospitals to use observation stays to avoid [...]