TY - JOUR T1 - The multiple aims of pay-for-performance and the risk of unintended consequences JF - BMJ Quality & Safety JO - BMJ Qual Saf SP - 827 LP - 831 DO - 10.1136/bmjqs-2016-005392 VL - 25 IS - 11 AU - Rocco Friebel AU - Adam Steventon Y1 - 2016/11/01 UR - http://qualitysafety.bmj.com/content/25/11/827.abstract N2 - Since the Affordable Care Act introduced financial penalties on hospitals for excess readmission rates in the USA, an intense debate has ensued regarding the value of readmissions as a marker of quality. Under the Hospital Readmission Reduction Program (HRRP), hospitals face penalties of up to 3% of base operating payment from Medicare, the federally funded health insurance system for people aged over 65. Penalties totalled $428 million in 2015,1 and similar policies are in place in Denmark, Germany and England.2HRRP aimed to ‘reward hospitals that are successful in reducing avoidable readmissions’3 and indeed Medicare has seen a decline in 30-day, all-cause readmission rates since the policy was introduced in 2012.4 More specific declines have been observed for the three conditions initially targeted, namely acute myocardial infarction, heart failure and pneumonia (figure 1).1 ,5 The HRRP was expanded to cover chronic obstructive pulmonary disease, total hip arthroplasty and total knee arthroplasty from 2015.Figure 1 Trend in national Medicare 30-day readmission rates for index admissions for heart failure, heart attack, pneumonia and all-cause Medicare readmissions.1 ,4While no study has been able to test causality against a counterfactual, on the face of it HRRP has contributed to a sustained focus on readmissions and potentially, improved patient care nationally. But what aspects of quality do readmission rates measure? And what are we to make of the findings reported in this issue of BMJ Quality and Safety,6 which indicate that, like other pay-for-performance programmes, readmission penalties have disproportionately affected safety-net hospitals (ie, hospitals that serve a high number of patients of lower socioeconomic status (SES), often uninsured).In theory, readmissions are related to the quality and safety of the initial hospital stay, the transitional care services and access to care and support following … ER -