10 Years After HRRP, the Search for Super-User Solutions Continues

By Thomas Crocker
Monday, November 29, 2021

The Hospital Readmissions Reduction Program (HRRP) has reduced readmission rates, but hospitals still struggle to find the most effective ways to serve their most frequent patients.

In 2012, CMS established the HRRP, which linked Medicare payments to readmission rates to galvanize hospitals to institute changes that would help keep patients out of their facilities. These patients included so-called super-users — a pejorative though widely-used term for the small percentage of individuals who account for a disproportionate amount of healthcare spending. The program has produced successes, but challenges remain.

Ten years after the HRRP’s inception, readmission rates for the program’s target conditions have declined faster than those of conditions not covered by the program, according to the Medicare Payment Advisory Commission. However, readmission rates remain near 16%, and, in 2021, 47% of hospitals saw their Medicare payments cut due to high readmission rates.

A Problem With Socioeconomic Roots

What is behind readmissions among super-users and others? Society of Hospital Medicine President-Elect Rachel Thompson, MD, MPH, SFHM, FACP, who is also Chief Medical Officer at Snoqualmie Valley Hospital and Health District in Washington state, points to gaps in social support more than poorly controlled medical conditions. She believes hospitals have improved their ability to reduce readmissions among patients with solid social support, but that has not translated to blanket success.

“Populations that struggle with homelessness, mental health and access to preventive and coordinated care are best served through multidisciplinary efforts and comprehensive, team-based care management,” Dr. Thompson says. “Unfortunately, these are expensive programs that many systems [find] challenging to launch. One thing that HRRP has done is shine a light on these complexities and, in some ways … forced us to at least think about design and process for people with broader needs.”

Readmission Reduction Strategies

Improving transitions of care is a key plank in many hospitals’ readmissions reduction strategies. Vanderbilt Health Affiliated Network reduced its Medicare Shared Savings Program readmission rates by nearly seven points, from 19.6% to 12.9%, after adopting its Transitions of Care Program. The program includes follow-up nursing outreach, assistance with medication management and coordination with patients’ primary care physician and specialists.

Another way to reduce readmissions is to move care for certain patients out of the hospital and into the home. That is what Intermountain Healthcare and its subsidiary, Castell, have done by offering hospital-level care at home to patients with a variety of acute and chronic conditions. Patients receive regular remote and in-home check-ins from providers, as well as a home monitoring kit and other medical equipment that allows telehealth specialists to track their health data around the clock.

In a 2020 study published in Annals of Internal Medicine, researchers at Brigham and Women’s Hospital and Harvard Medical School found that, among patients requiring hospital admission, 7% who received hospital-level care at home required readmission to the hospital compared with 23% of patients who received usual hospital care.