Encore! EP326: The Unfortunate News About HRRP, With Insight Into How to Fix It, With Rishi Wadhera, MD, MPP

HRRP stands for Hospital Readmissions Reduction Program, by the way.

I wanted to encore this episode with Dr. Rishi Wadhera because it’s a great representation of a common root cause reason why quality metrics sometimes don’t end well in real life. This root cause is otherwise known as Goodhart’s Law, and we dig into Goodhart’s law later on in this healthcare podcast.

But the actual and ultimate impact of HRRP is also a pretty good representation of the consequences, what happens, when you create a blunt-force policy that assumes hospitals with very different circumstances are the same.

Before we kick in to the episode, I asked Dr. Wadhera, my guest today as aforementioned, if there’d been any updates regarding HRRP since this show originally aired last year; and he told me that two key pieces have come out this past month in JAMA journals calling out CMS (Centers for Medicare & Medicaid Services) to move on from/retire this policy:

A Decade of Observing the Hospital Readmission Reductions Program—Time to Retire an Ineffective Policy

Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns?

Thanks so much to Dr. Steve Schutzer and also BoneDoc66 for your really nice reviews this past month. So appreciated … thank you so much!

And here is your encore.

Today’s guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this healthcare podcast. Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master’s in public policy at the Harvard Kennedy School of Government and also a master’s in public health from the University of Cambridge.

But here’s the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this healthcare podcast and which my nerd heart could not love more: Goodhart’s Law. This law is the root of so very many problems. Goodhart’s Law is this (which I learned from Dr. Wadhera): “When a measure becomes a target, it ceases to be a good measure.” In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. Maybe because bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. For example, teaching to the test may not lead to students who deeply understand a subject.

And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, “Sometimes the shortest way home is the long way around.”

Rishi K. Wadhera, MD, MPP, MPhil, is an assistant professor of medicine at Harvard Medical School, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC), and the associate program director of the cardiovascular medicine fellowship at BIDMC. He is also health policy and equity researcher at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

Dr. Wadhera received his MD from the Mayo Clinic School of Medicine as well as an MPhil in public health as a Gates Cambridge Scholar from the University of Cambridge. He completed his internal medicine residency and cardiovascular medicine fellowship at Brigham and Women’s Hospital in Boston. During this time, he also received a master’s in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy.

Dr. Wadhera’s research spans questions related to healthcare access, quality, and disparities, as well as understanding how local, state, and national policy initiatives impact care delivery, health equity, and outcomes. Dr. Wadhera has published more than 80 articles to date, and he receives research support from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH)

03:30 What was the Hospital Readmissions Reduction Program intended to do?

05:22 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable?

06:02 “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.”

06:58 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program?

08:16 “The 30-day readmission measure—it’s an incomplete measure.”

11:48 “I think patients … are smart, and they know what’s going on.”

13:34 “What’s happening is, we’re just increasing the number of times they need to come back to the ER within that 30-day period.”

13:55 “The weird thing about the HRRP is that when it evaluates hospitals’ 30-day readmission rates, it’s a yes-no phenomenon.”

15:03 “What CMS does is, it risk adjusts … and that is what we should be doing.”

18:30 “This program has been incredibly regressive.”

19:04 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals’ control.”

21:50 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.”

22:06 “It just makes no sense to take resources away from hospitals.”

22:32 EP295 with Rebecca Etz, PhD, of The Larry A. Green Center.

23:47 What’s the way to improve quality of care globally?

25:37 “CMS’s approach to improving quality of care has really anchored … [that] to payment.”

26:08 “It’s time for us to rethink what our approach to quality improvement should be.”

29:22 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.”

31:41 Can you scale healthcare nationally?

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370)