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

I wanted to encore this episode with Dr. Rishi Wadhera because it\u2019s a great representation of a common root cause reason why quality metrics sometimes don\u2019t end well in real life. This root cause is otherwise known as Goodhart\u2019s Law, and we dig into Goodhart\u2019s 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\u2019d 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\u2014Time 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 \u2026 thank you so much!

And here is your encore.

Today\u2019s 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\u2019s in public policy at the Harvard Kennedy School of Government and also a master\u2019s in public health from the University of Cambridge.

But here\u2019s 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\u2019s Law. This law is the root of so very many problems. Goodhart\u2019s Law is this (which I learned from Dr. Wadhera): \u201cWhen a measure becomes a target, it ceases to be a good measure.\u201d 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, \u201cSometimes the shortest way home is the long way around.\u201d

You can learn more at Dr. Wadhera\u2019s 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\u2019s Hospital in Boston. During this time, he also received a master\u2019s in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy.

Dr. Wadhera\u2019s 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)

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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 \u201cThe spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve \u2026 discharge planning, transitions of care, and post-discharge follow-up and care.\u201d

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

08:16 \u201cThe 30-day readmission measure\u2014it\u2019s an incomplete measure.\u201d

11:48 \u201cI think patients \u2026 are smart, and they know what\u2019s going on.\u201d

13:34 \u201cWhat\u2019s happening is, we\u2019re just increasing the number of times they need to come back to the ER within that 30-day period.\u201d

13:55 \u201cThe weird thing about the HRRP is that when it evaluates hospitals\u2019 30-day readmission rates, it\u2019s a yes-no phenomenon.\u201d

15:03 \u201cWhat CMS does is, it risk adjusts \u2026 and that is what we should be doing.\u201d

18:30 \u201cThis program has been incredibly regressive.\u201d

19:04 \u201cPoverty, neighborhood disadvantage, housing instability\u2014these factors are out of hospitals\u2019 control.\u201d

21:50 \u201cBlunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.\u201d

22:06 \u201cIt just makes no sense to take resources away from hospitals.\u201d

22:32 EP295 with Rebecca Etz, PhD.

23:47 What\u2019s the way to improve quality of care globally?

25:37 \u201cCMS\u2019s approach to improving quality of care has really anchored \u2026 [that] to payment.\u201d

26:08 \u201cIt\u2019s time for us to rethink what our approach to quality improvement should be.\u201d

29:22 \u201cPolicy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.\u201d

31:41 Can you scale healthcare nationally?

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You can learn more at Dr. Wadhera\u2019s Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.

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@rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

What was the Hospital Readmissions Reduction Program intended to do? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

Why did CMS think some readmissions were preventable? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cThe spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve \u2026 discharge planning, transitions of care, and post-discharge follow-up and care.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cThe 30-day readmission measure\u2014it\u2019s an incomplete measure.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cWhat CMS does is, it risk adjusts \u2026 and that is what we should be doing.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cBlunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cIt just makes no sense to take resources away from hospitals.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

What\u2019s the way to improve quality of care globally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

\u201cIt\u2019s time for us to rethink what our approach to quality improvement should be.\u201d @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

Can you scale healthcare nationally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission

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