EP326: The Unfortunate News About HRRP, With Insights on How to Fix It, With Rishi Wadhera, MD, MPP

In Episode 326, Stacey Richter talks with Rishi Wadhera, MD, MPP, cardiologist at Beth Israel Deaconess Medical Center, about his retrospective analysis of the Hospital Readmissions Reduction Program (HRRP) — and how Goodhart's Law explains why so many value-based care and quality metrics backfire.

WHAT YOU'LL LEARN

✅ What the Hospital Readmissions Reduction Program was originally intended to do

✅ Why the 30-day readmission measure is an incomplete way to judge hospital quality

✅ How HRRP penalties have disproportionately and regressively hurt hospitals serving disadvantaged communities

✅ Why tying quality improvement directly to payment can create perverse incentives

✅ Why policymakers should rigorously test policies before rolling them out nationally

WHY THIS MATTERS

Goodhart's Law — "when a measure becomes a target, it ceases to be a good measure" — is the root of a lot of what goes wrong in value-based care. HRRP penalizes hospitals for 30-day readmissions using a blunt, yes-no measure that doesn't account for factors like poverty and housing instability that are outside a hospital's control, and it can end up pulling resources away from the hospitals that need them most. Anyone designing quality programs or chasing value-based care success should take the lesson to heart: sometimes the shortest way home is the long way around.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

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?