The rate at which patients returned to the hospital within 30 days of hospitalization for heart attack, heart failure or pneumonia dropped more after healthcare reform than before for hospitals receiving penalties, according to new research presented Monday at the American Heart Association’s QCOR 2016 Scientific Sessions in Phoenix, Arizona.

“We present strong evidence that the roll-out of the penalty caused hospitals to improve their readmission rates,” said lead researcher Dr. Jason Wasfy, a cardiologist at Massachusetts General Hospital in Boston.

Thirty-day hospital readmissions cost Medicare more than $17 billion a year, according to a 2009 New England Journal of Medicine study.  The Affordable Care Act, which took effect in 2010, sought to limit readmissions by reducing Medicare reimbursement funds for hospitals it deemed had excessive 30-day readmissions for heart attack, heart failure or pneumonia.

Historically, there had not previously been a financial motivation for U.S. hospitals to decrease readmission rates since patients returning to the hospital requiring more treatment actually meant more money for the hospitals. But the Hospital Readmissions Reduction Program made the readmission numbers transparent and levied reimbursement fund penalties.

To start in October 2012, penalties were 1 percent of the hospital’s total Medicare reimbursement. Ultimately, the penalties will grow to 3 percent.

Wasfy’s research team used Medicare records from 2000 until 2013 to determine how the first round of penalties issued from October 2012 -October 2013 affected readmission rates.

During that first year, 9 percent of hospitals received the maximum 1 percent penalty, 16.8 percent received a high penalty, and 44 percent received a low penalty. Large teaching hospitals were the most penalized and rural hospitals, the least, according to the research.

Prior to healthcare reform, readmissions were dropping in hospitals that didn’t receive penalties but increasing in high and maximum penalty groups. After the law, readmission rates dropped more quickly in hospitals penalized the most, and dropped for all penalty groups.

Penalties under the ACA were designed to reduce costs and unnecessary return hospital visits, and improve the quality of patient care, Wasfy said. Before the law, hospitals made more money by readmitting patients, whether patients needed care or not.

“A lot of research has suggested that readmissions are largely preventable,” he said. “The hope is that by assessing financial penalties, hospitals will pay more attention to what patients need.”

University of California Los Angeles cardiologist Dr. Gregg Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center, said reductions in readmission rates were modest, despite being statistically significant.

He said the key issues are whether this reflects improvement in patient-centered quality or care or that hospitals are instead “gaming” the system by delaying readmissions slightly more than 30 days or readmitting patients for observation, which does not apply to readmission rates.  It’s also important to measure whether reducing readmissions is having unintended consequences like more deaths, he said.

Wasfy agreed.

“We need to understand more about how to design pay for performance measures to minimize manipulation and maximize quality improvement,” Wasfy said. “If we understood better how metrics change physician performance, we’d be able to recommend better policies that could help more patients.”

Wasfy said a 2013 Journal of the American Medical Association study found no substantial relationship between 30-day readmission rates and deaths.

A recent New England Journal of Medicine study found that observation stays did not change significantly as a result of healthcare reform, although they have continued a steady increase.

His own hospital, Massachusetts General in Boston, has lowered its 30-day readmissions with follow-up phone calls to discharged patients to explain medications and video-based health coaching to help people understand and interpret their symptoms correctly and manage their anxiety, so that they don’t return to the hospital unnecessarily.

Patients and doctors both have a role in reducing 30-day readmissions, Wasfy said.  Doctors should be responsible for empowering patients to understand their disease, know which symptoms to watch for, and when to get in touch with their cardiologist.

“We need to move on from a paradigm where doctors just tell patients what to do,” he said.

The best way for patients to avoid being readmitted to the hospital, Fonarow said, is to avoid being admitted in the first place. He recommends more focus on preventing heart attacks, heart failure and pneumonia by managing risk factors and providing vaccination for pneumonia and influenza.

Otherwise, it’s a challenge for hospitals to reduce their 30 day readmissions while still focusing on other critical aspects of patient quality of care and outcomes. They can’t control the fact that heart failure patients are generally older and sicker, and half of them have heart failure with preserved ejection fraction, the type lacking effective, science-based treatments. Health literacy of patients and social determinates of health also come into play, Fonarow said.

The key is for hospitals to focus on patient safety, quality of care, longer-term survival and readmissions beyond 30 days.

Meanwhile, Wasfy is encouraged that the financial incentives contributed to reducing readmission rates.

“We have to figure out how to pay hospitals for doing better not more for doing more.”