NURS 6050 Healthcare Program/Policy Evaluation Analysis Template Example: Hospital Readmissions Reduction Program (HRRP)

The Medicare Hospital Readmissions Reduction Program (HRRP), a federal value-based purchasing policy, and its published evaluations (Joynt & Jha, 2013; Wadhera et al., 2018; Zuckerman et al., 2016).

The HRRP was created by Section 3025 of the Affordable Care Act to reduce avoidable 30-day hospital readmissions among Medicare fee-for-service beneficiaries. Beginning October 1, 2012 (fiscal year 2013), CMS reduced inpatient payments to acute care hospitals whose readmission rates for acute myocardial infarction (AMI), heart failure (HF) and pneumonia exceeded risk-adjusted expectations (Joynt & Jha, 2013). Chronic obstructive pulmonary disease, elective total hip and knee arthroplasty and coronary artery bypass graft surgery were added later. The maximum penalty rose from 1% to 3% of base Medicare payments, and since fiscal year 2019 hospitals have been compared with peer hospitals serving similar proportions of patients dually eligible for Medicare and Medicaid.

The intended outcomes were fewer unplanned readmissions, better discharge planning and care transitions, lower Medicare spending and stronger hospital accountability for what happens after discharge.

CMS measures success with each hospital’s excess readmission ratio: the hospital’s risk-standardized predicted 30-day unplanned readmissions divided by the expected number for an average hospital with similar patients. A ratio above 1.0 triggers a penalty. Independent evaluations measured national trends in 30-day readmission rates for targeted and nontargeted conditions, use of observation stays and 30-day post-discharge mortality (Wadhera et al., 2018; Zuckerman et al., 2016).

Reach: the HRRP applies to roughly 3,000 acute care hospitals paid under Medicare’s inpatient prospective payment system and therefore to millions of Medicare discharges each year. For fiscal year 2027, CMS penalized 2,334 hospitals, about 80% of those evaluated (Parduhn, 2026).

Impact: from October 2007 to May 2015, readmission rates for the targeted conditions fell from 21.5% to 17.8%, and rates for nontargeted conditions fell from 15.3% to 13.1%, with the steepest declines after the law was passed; rising observation stays did not explain the decline (Zuckerman et al., 2016). Most penalized hospitals lose less than 1% of Medicare base payments (Parduhn, 2026).

The key evaluations were summative (outcome) evaluations conducted several years after implementation. Zuckerman et al. (2016) compared three periods: before the law (2007–2010), after enactment but before penalties (2010–2012) and after penalties began (2012–2015). Wadhera et al. (2018) analyzed mortality from 2005 to 2015, also comparing pre-announcement, announcement and implementation periods. Joynt and Jha (2013) conducted an early evaluation at the start of implementation, analyzing which hospitals received the first penalties.

Medicare claims data, including inpatient stays, observation stays and readmissions; Medicare enrollment files for deaths after discharge; CMS hospital penalty files; and hospital characteristics such as teaching status, size, ownership and the share of low-income patients served (Joynt & Jha, 2013; Wadhera et al., 2018; Zuckerman et al., 2016).

Possible increase in mortality: after implementation, 30-day post-discharge mortality increased for HF and pneumonia, mainly among patients who were not readmitted, raising concern that some patients who needed readmission were not readmitted, although the study design limits causal conclusions (Wadhera et al., 2018).

Penalties on safety-net and teaching hospitals: hospitals serving larger shares of low-income patients and major teaching hospitals were more likely to be penalized, reducing resources for hospitals caring for vulnerable populations (Joynt & Jha, 2013). This finding led Congress to require peer grouping by dual-eligible status.

Possible gaming: concern that hospitals might shift patients to observation status or emergency department visits instead of readmitting them, although Zuckerman et al. (2016) found no significant association between rising observation stays and falling readmissions.

Stakeholders: CMS and Congress (policymakers who design and fund the program); hospitals and health systems, especially safety-net and teaching hospitals; Medicare beneficiaries and caregivers; nurses, physicians, case managers and pharmacists who plan discharges; post-acute and primary care providers; and researchers and advisory bodies such as the Medicare Payment Advisory Commission.

Those who benefit most: policymakers, who used evaluation results to add socioeconomic peer grouping; hospital leaders, who use results to target programs such as heart failure transition clinics; and patients with HF and pneumonia, whose safety depends on balancing readmission reduction with access to needed hospital care. For example, a hospital quality committee could use the mortality findings to add a post-discharge mortality measure to its readmission dashboard.

Partially. The HRRP met its primary objective of reducing readmissions for targeted conditions and encouraged hospitals nationwide to invest in discharge planning and care transitions, with some spillover to nontargeted conditions (Zuckerman et al., 2016). However, it did not fully meet the broader intent of improving the quality of care for all patients, because evaluations raised concerns about higher post-discharge mortality for HF and pneumonia and penalized hospitals serving the poorest patients (Joynt & Jha, 2013; Wadhera et al., 2018). Readmission rates alone do not capture whether patients are better off.

As a federal payment policy, the HRRP already applies to most acute care hospitals, so the practical question is how my hospital responds. I would recommend fully implementing evidence-based readmission-reduction practices, such as teach-back discharge education, medication reconciliation, follow-up appointments scheduled before discharge and 48- to 72-hour follow-up calls, because these improve care transitions for all patients. However, I would recommend balancing readmission targets with patient safety by monitoring 30-day mortality and emergency department returns, so that staff never feel pressure to avoid medically necessary readmissions. [Replace with your own workplace and its readmission data.]

Join the hospital’s readmission or quality improvement committee to review one-year data on readmissions, post-discharge mortality and patient experience, and help conduct root cause analyses of individual readmissions to identify nursing-related factors such as gaps in discharge teaching.

Collect and analyze unit-level data, for example by auditing teach-back documentation or tracking the results of follow-up phone calls, and present findings to nursing leadership.

Advocate at the policy level by submitting public comments on CMS’s annual inpatient payment proposed rule or working through professional organizations such as the American Nurses Association to recommend measures that capture patient safety, not only readmissions.

The HRRP shows both the power and the limits of financial incentives. Readmissions declined, but evaluations revealed unintended consequences that would not have been visible without independent evaluation. Nurses, who lead discharge education and care transitions, are well positioned to help ensure that policies designed to reduce costs also improve patient outcomes.