Also Appearing in This Issue of JAMA


Study Identifies What Type of Hospitals are More Likely to Receive Penalties For Failing to Reduce Hospital Readmissions

“The federal Hospital Readmissions Reduction Program (HRRP) took effect on October 1, 2012, the first day of fiscal year 2013. Under this program, using claims data from July 2008 through June 2011, the Centers for Medicare & Medicaid Services (CMS) determined, for each eligible U.S. hospital, whether their readmission rates were higher than would be predicted by CMS models based on their case mix. Hospitals with higher-than-predicted readmission rates will have their total Medicare reimbursement for fiscal year 2013 cut by up to 1 percent based on these calculations. The CMS recently made these payment cuts public,” writes Karen E. Joynt, M.D., M.P.H., of Brigham and Women’s Hospital, and Ashish K. Jha, M.D., M.P.H., of the Harvard School of Public Health, Boston. The authors conducted a study to examine the risk of penalties for U.S. hospitals that care for medically complex or socioeconomically vulnerable patients, namely large teaching hospitals and safety-net hospitals.

As reported in a Research Letter, the authors used the publicly available HRRP Supplemental Data File and categorized hospitals as having high penalties (top half of penalized hospitals), low penalties (bottom half), and no penalties. These data were linked to the 2011 American Hospital Association annual survey to identify hospitals that likely care for sicker patients (large hospitals with 400 or more beds and major teaching hospitals with membership in the Council of Teaching Hospitals) as well as safety-net hospitals (SNHs, those in the highest quartile of the disproportionate share hospital index, a measure used by the CMS to quantify care provided for the poor).

“We found that large hospitals, teaching hospitals, and SNHs are more likely to receive payment cuts under the HRRP. It is unclear exactly why these hospitals have higher readmission rates than their smaller, non-teaching, non-SNH counterparts, but prior research suggests that differences between hospitals are likely related to both case mix (medical complexity) and socioeconomic mix of the patient population. There is less evidence that differences in readmissions are related to measured hospital quality.”

(JAMA. 2013;309[4]:342-343. Available pre-embargo to the media at


Viewpoints in This Issue of JAMA

Thirty-Day Readmissions – The Clock Is Ticking

In this Viewpoint, Muthiah Vaduganathan, M.D., M.P.H., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues discuss the widely accepted 30-day time frame that is often used to help define response to therapies, and the use of rehospitalization as a target end point. The authors use heart failure as an example to point out the various facets of postdischarge hospital outcomes.

“Heart failure is a chronic, undulating condition. Focusing on an arbitrary time frame and end point inadequately characterizes the situation. A more nuanced and comprehensive approach is required to effectively alter the postdischarge course of patients admitted for heart failure and other conditions. Specific quality metrics should be rigorously tested and validated in target populations to ensure those measures are feasible and effective for improving the clinical end points. Longer-term end points may help capture a larger at-risk population and reduce the early competing risks of mortality and rehospitalization. Clear criteria for admission, readmission, and discharge must be established to encourage necessary admissions for appropriate length of stay.”

(JAMA. 2013;309[4]:345-346. Available pre-embargo to the media at

Time to Get Serious About Pay for Performance

In this Viewpoint, Ashish K. Jha, M.D., M.P.H., of the Harvard School of Public Health, Boston, addresses three issues regarding pay for performance: incentive size, incentive structure, and metric choice; and how pay for performance initiatives might be improved.

“Pay for performance—putting real money at risk to motivate hospitals to take responsibility for patient outcomes— remains an attractive notion. However, it will only succeed by making bold choices, monitoring its effects closely, and changing the approach when the evidence suggests it is not working. Experimentation with different models that put more dollars at risk for poorly performing hospitals may be one option, using these dollars to focus them on patient outcomes. While some institutions will lose in this new scheme, their patients are already losing now—too many continue to have adverse outcomes in U.S. hospitals because of poor-quality care. Pay for performance represents an enormous opportunity to right the ship, but only if policy makers are willing to be courageous, learn along the way, and remain focused on the primary mission of the health care system: to ensure that patients achieve the best outcomes possible.”

(JAMA. 2013;309[4]:347-348. Available pre-embargo to the media at


Tension Between Quality Measurement, Public Quality Reporting, and Pay for Performance

Steven A. Farmer, M.D., Ph.D., of the Northwestern University Feinberg School of Medicine, Chicago, and colleagues examine reasons why two major initiatives that seek to improve quality of U.S. health care—public reporting of outcomes and pay for performance (P4P)—“have the potential to reduce the reliability of the administrative data on which they are often based and generate spurious estimates of performance.”

“How can outcomes be measured without abandoning P4P or public reporting? There is need for a national, standardized system for outcome reporting. This system must be separate from billing data and structured so that it is minimally affected by the incentives to alter coding created by public reporting and P4P. The system should be designed to provide time-consistent measures of actual outcomes, which billing data do not. A new outcome reporting system will not be simple or inexpensive, but there appear to be no alternatives to this approach.”

“Quality improvement efforts must engage hospitals in capturing accurate and timely quality information not because regulators seek data, but to ensure that their health care product provides optimal care and is competitive in the marketplace.”

(JAMA. 2013;309[4]:349-350. Available pre-embargo to the media at


Recasting Readmissions by Placing the Hospital Role in Community Context

Douglas McCarthy, M.B.A., of the Institute for Healthcare Improvement, Cambridge, Mass., and colleagues “suggest that it may be more advantageous to view [hospital] readmissions within a broader systems and community context that effectively engages all stakeholders to cooperatively improve outcomes.” The authors also discuss the Hospital Readmissions Reduction Program (established by the U.S. Affordable Care Act), which requires the Centers for Medicare & Medicaid Services to reduce Medicare payments to hospitals with excess readmissions for select conditions.

“The Hospital Readmission Reduction Program has raised awareness of readmissions as an indicator of a fragmented health care delivery system. Yet financial penalties alone are not likely to drive change. As the nation moves toward comprehensive payment and delivery system reforms to promote integrated care, the focus should shift toward reducing avoidable hospital use, not just readmission, by strengthening primary and preventive care and chronic disease management for populations of patients at risk of poor health outcomes.”

(JAMA. 2013;309[4]:351-352. Available pre-embargo to the media at

Editor’s Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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