Here’s the context, friends: As you may have noticed over the past few episodes, we have been digging into value-based care here at Relentless Health Value corporate work-from-home headquarters. Many lessons have been learned, and it’s important that we sit back and think hard every now and then about how we are going to use these learnings to improve.
While this show tackles the Hospital Readmissions Reduction Program (HRRP)—and wow, I was glued to my seat during this interview—the show is really about more than that, which I’ll get into in 30 seconds.
But let’s start here: HRRP was originally part of the Affordable Care Act in 2010. In 2012, HRRP began imposing penalties on hospitals with higher-than-expected 30-day readmission rates for three conditions: heart failure, myocardial infarction, and pneumonia. Spoiler alert: More recently, CABG, THA/TKA, and COPD were added to the list.
So basically, if a patient is in the hospital for any of these six things and then is readmitted to the hospital for any reason within 30 days, penalties can happen.
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 health care podcast. His findings are fascinating and relevant on a number of levels.
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. Dr. Wadhera works on policy at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.
But here’s the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this health care 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. For example, teaching to the test may not actually lead to students who deeply understand a subject.
Here’s another example, and Rebecca Etz, PhD, talks about this in EP295: If you want PCPs to do an amazing job managing diabetes, for example, the best measures are ones that quantify the doctor’s relationship with the patient and the amount of trust between them. The second you start using their panel’s average A1C as the performance metric, A1Cs at best don’t improve. Why? 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. It doesn’t go well. It’s like salespeople who try to close before they build a relationship. Time to goal counterintuitively is slower, and performance is poorer.
Anyone building value-based care or quality programs might really want to include Goodhart’s Law in their thinking. 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.”
You can learn more at Dr. Wadhera’s Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.
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 health care 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).
03:10 What was the Hospital Readmissions Reduction Program intended to do?
05:05 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable?
05:46 “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.”
06:54 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program?
08:14 “The 30-day readmission measure—it’s an incomplete measure.”
12:12 “I think patients … are smart, and they know what’s going on.”
14:01 “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.”
14:22 “The weird thing about the HRRP is that when it evaluates hospitals’ 30-day readmission rates, it’s a yes-no phenomenon.”
15:30 “What CMS does is, it risk adjusts … and that is what we should be doing.”
19:16 “This program has been incredibly regressive.”
19:51 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals’ control.”
22:56 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.”
23:12 “It just makes no sense to take resources away from hospitals.”
25:22 What’s the way to improve quality of care globally?
27:19 “CMS’s approach to improving quality of care has really anchored … [that] to payment.”
27:49 “It’s time for us to rethink what our approach to quality improvement should be.”
31:28 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.”
34:05 Can you scale health care nationally?