After Medicare’s Hospital Readmissions Reduction Program (HRRP) began enforcing financial penalties for higher-than-expected 30-day readmission rates for targeted clinical conditions in 2012, racial disparities may have widened further, according to a study published in JAMA Network Open.  

Researchers in this cohort study analyzed Medicare data on 58,237,056 patients discharged between 2007 and 2015 to assess readmission rate disparities between black and white patients at safety-net or non-safety-net hospitals after the enforcement of the HRRP began.

Discharges for all clinical conditions were evaluated and categorized into subsets of HRRP targeted and non-targeted conditions.

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Primary outcomes were trends in 30-day rates of readmission among black and white patients by quarter, as well as differences between trends across 3 periods: (1) Pre-Affordable Care Act (ACA) period: before April 1, 2010, when the ACA was implemented; (2) HRRP implementation period: after ACA implementation but before enforcement of HRRP penalties began October 1, 2012; and (3) HRRP penalty period: after enforcement of HRRP penalties.

Of the total patient discharges from 3871 different hospitals (46,999,814 or 80.7% from non–safety-net hospitals and 11,237,242 or 19.3% from safety-net hospitals), 13.5% discharges (n=7,864,250) were for targeted conditions and 86.5% (n=50,372,806) were for non-targeted conditions.

Among all patient discharges, 57.7% were women, 9.8% were black, the mean age was 78.8±7.9 years, and 16.8% had dual enrollment in both Medicare and Medicaid. No differences were seen in hospital characteristics or patient demographics across the 3 time periods.

In the HRRP implementation period, a narrowing of racial disparities between black and white patients was seen in safety-net hospitals by a 0.11 percentage point reduction per quarter (95% CI, −0.13 to −0.07; P <.001), with a smaller narrowing of disparities seen in non-safety-net hospitals (0.05 percentage point per quarter decrease [95% CI, −0.07 to −0.03]; P <.001).

In the HRRP penalty period at safety-net hospitals, racial disparities in rates of readmission for all clinical conditions widened by 0.04 percentage points per quarter between black and white patients (95% CI, 0.01-0.07; P =.01).

Disparities for conditions targeted by the HRRP did not change (increase of 0.01 percentage point per quarter [95% CI, −0.07 to 0.10]; P =.74) but were rather driven by non-targeted conditions (increase of 0.05 percentage point per quarter [95% CI, 0.01-0.08]; P =.006).

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Racial disparities at non-safety-net hospitals in the HRRP penalty period remained stable across all conditions and for both HRRP-targeted and non-targeted conditions.

Study investigators concluded that “the implementation period between the enactment of the ACA and the HRRP’s enforcement of penalties is a critical period of improved equity between races irrespective of the hospital’s safety-net status or the patient’s clinical condition. Discovering what contributed to these observed trends and how readmission penalties are influencing hospital behavior will help future efforts aimed at improving equity within health care.”


One study author reports being a consultant for CarePort Health. Please refer to original reference for full list of disclosures.


Chaiyachati KH, Qi M, Werner RM. Changes to racial disparities in readmission rates after Medicare’s hospital readmissions reduction program within safety-net and non–safety-net hospitals [published online November 2, 2018]. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.4154