Unintended Consequences of Medicare Policy for Post-Hospital Injuries among Older Adults

Summary

The proposed project addresses prevention of older adult falls. Falls remain a worrisome public threat that is growing with the aging of the US population and the recent pandemic. Risk factors are well established and numerous effective interventions exist, but are largely unused. Therefore, novel approaches to understanding and addressing fall risk are required. These include evaluations of policy factors that likely impede prevention efforts. Local interventions are vital to address social and physical engagement, mobility, and physical conditioning, yet national policies may be key to population-wide fall prevention. The incentive to avoid Medicare penalties for excess readmission under the national Hospital Readmissions Reduction Program (HRRP) may create disincentives to identify and address patient functional needs, particularly when physical deconditioning threatens older adult safety at a hospital discharge. Care coordination across multiple providers needed for fall prevention may also be compromised due to these HRRP incentives. However, this topic has not previously been explored.

It innovatively responds to a CDC research gap and priority, "Explain the critical factors that influence changing trends in falls and fall-related injury rates among older adults." It assesses potential unanticipated consequences from a federal policy to introduce "high-value care," but which may have increased in fall injury rates among older Americans. That HRRP focuses on 30-day utilization may have reduced attention to longer-term functional outcomes, also altering in-hospital care and post-acute rehabilitation use, which could have amplified fall risks among Medicare's 45 million older enrollees. With this evaluation, our proposal can inform policy regarding older adult welfare and safety, while moving forward the science on CDC and IPC priority areas. Findings identifying HRRP harms could amplify advocacy efforts, such as a targeted Medicare falls benefit that would expand care options beyond a "medically necessary services" policy that prioritizes care after, as opposed to before, an injury.

Abstract

This research will use national Medicare hospital claims to evaluate a Medicare pay-for-performance policy introduced to address quality of care, the Hospital Readmission Reduction Program (2014-present). HRRP penalized hospitals for excess readmissions for targeted conditions (e.g., heart failure, pneumonia). We will assess whether HRRP impacted older adult fall injury, overall and for lower-performing hospitals and for beneficiaries at high risk for fall injury (Aim 1). We will also explore mechanisms associated with any changes after HRRP implementation; specifically, we will explore whether hospitals that had reduced fall injury risk used gaming (putting off readmissions past the 30-day measurement window), patient selection (avoiding patients at greater risk for fall injury), or treatment intensity (improved nurse-staffing ratios, different post-acute referral patterns) (Aim 2). The two aims will be evaluated using a difference-in-differences and triple differences study design that compares changes in fall injuries and mechanisms before and after implementation of HRRP, for hospitals that are high versus low-performing, comparing targeted conditions and a non-targeted condition that has not been shown to have been impacted under HRRP. These analyses will provide causal estimates of the impact of HRRP on outcomes and mechanisms that may explain that impact.