Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program

Health Serv Res. 2019 Apr;54(2):327-336. doi: 10.1111/1475-6773.13133.


Objective: Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties.

Study design: Retrospective cohort study.

Data sources/study setting: Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015.

Principal findings: Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals.

Conclusions: Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.

Keywords: Medicare; readmission.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Disabled Persons / statistics & numerical data
  • Economics, Hospital
  • Female
  • Health Status Disparities
  • Heart Failure / epidemiology
  • Humans
  • Insurance Claim Review / statistics & numerical data
  • Male
  • Medicaid / statistics & numerical data
  • Medicare / organization & administration*
  • Medicare / standards
  • Myocardial Infarction / epidemiology
  • Patient Readmission / economics
  • Patient Readmission / statistics & numerical data*
  • Pneumonia / epidemiology
  • Quality Improvement / organization & administration
  • Residence Characteristics / statistics & numerical data
  • Retrospective Studies
  • Risk Adjustment / organization & administration*
  • Risk Factors
  • Safety-net Providers / organization & administration*
  • Safety-net Providers / standards
  • Socioeconomic Factors
  • United States