| Course | NUR-8100 Health, Healthcare Policy, and Politics |
|---|---|
| Module | Module 3 |
| Paper type | Quality and payment policy analysis |
| Length | About 1,068 words, 6 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | Doctor of Nursing Practice |
| Updated | October 2026 |
Free sample paper for NUR 8100 Module 3
Fewer Returns, More Deaths at Home? The Hospital Readmissions Reduction Program Through an Organization's Eyes
Student Name
Doctor of Nursing Practice, Thomas Edison State University
NUR-8100: Health, Healthcare Policy, and Politics
Mentor Name
Month Day, Year
Fewer Returns, More Deaths at Home? The Hospital Readmissions Reduction Program Through an Organization's Eyes
Introduction
Medicare has long paid hospitals for each admission regardless of what happens after discharge. A patient who returned within a month generated a second payment. The Hospital Readmissions Reduction Program, part of the Affordable Care Act, changed that incentive. Beginning in the fall of 2012, Medicare has docked as much as 3 percent of a hospital's regular payments when too many of its patients with certain diagnoses come back within a month. The program was intended to improve discharge planning and care transitions. This paper asks what it achieved, what it may have harmed and how a hospital should respond.
How the Program Works
Each year, Medicare calculates a risk-adjusted 30-day readmission ratio for each hospital for heart failure, acute myocardial infarction, pneumonia and, later, chronic obstructive pulmonary disease, hip and knee replacement and coronary bypass surgery. Hospitals with ratios above expected are penalized on all their Medicare base payments, not only those for the targeted conditions. Starting in 2019, a hospital's readmissions are compared only with those of hospitals whose patients are as often dual eligible, a change won by safety-net hospitals that said they were being fined for their patients' poverty.
Did Readmissions Fall?
Zuckerman et al. (2016) analyzed monthly readmission and observation stay rates in 3,387 hospitals from 2007 to 2015 using an interrupted time series. Return visits within a month for the penalized diagnoses slid from about one in five to under one in five and a half, and returns for other diagnoses fell too, from 15.3 to 13.1 percent. The steepest decline came soon after the law passed in 2010, before penalties began, suggesting that hospitals responded to the announcement. Meanwhile more patients who came back were kept under observation status, which escapes the penalty count, and skeptics asked whether returns were being relabeled instead of avoided. However, within hospitals, the authors found no significant association between increases in observation stays and decreases in readmissions, which suggests that relabeling did not explain the fall.
Did Patients Die More Often?
A harder question is whether pressure to avoid readmissions led hospitals to keep sick patients out. Wadhera et al. (2018) followed a decade of Medicare stays, more than eight million admissions for the three original conditions between 2005 and 2015. Measured against the earlier trend, heart failure and pneumonia patients died more often in their first month home once the program was announced and again once fines began, while heart attack patients did not. The worrying part is where the added heart failure deaths fell: mostly among people who were never readmitted at all. Records like these cannot prove the penalty killed anyone, and some later analyses disagree, but the signal was strong enough to alarm policymakers.
A second study pointed the same way using clinical registry data rather than claims. Gupta et al. (2018) used a national heart failure quality registry linked to Medicare claims, tracking well over a hundred thousand discharges. Once fines were in force, risk-adjusted returns within a month dropped by about a point and a half while deaths within a month climbed from 7.2 to 8.6 percent, and deaths within a year from 31.3 to 36.3 percent. The authors described the association as temporal and called for confirmation, and they suggested that if it held, the program's application to heart failure might need to be reconsidered. Two studies with different data sources finding a similar pattern make the concern harder to dismiss, even though neither can establish cause.
| Finding | Study | Implication |
|---|---|---|
| Readmissions fell, mainly after the law passed | Zuckerman et al. (2016) | Hospitals responded to the incentive |
| Observation stays rose but did not explain the fall | Zuckerman et al. (2016) | Relabeling was not the main mechanism |
| More deaths in the month after going home | Wadhera et al. (2018) | Possible harm from avoiding readmission |
The Organization Perspective
For hospitals, the program created a financial reason to invest in transitions: discharge teaching, follow-up calls, early clinic appointments, medication reconciliation and partnerships with skilled nursing facilities. Many hospitals hired nurses as transition coaches. Safety-net hospitals faced a harder position. People leaving these hospitals more often go home to empty refrigerators, unreliable rides and uncertain housing, any of which can bring them back no matter how good the inpatient care was. Before peer grouping, these hospitals were penalized more often, reducing the resources they had to improve. The program also gave hospitals an incentive to treat returning patients in the emergency department or observation, which may be appropriate for some patients and harmful for others.
The Patient and Workforce Perspectives
For patients, fewer readmissions is good if it reflects better care at home, and bad if it reflects discouragement from returning when they need to. Heart failure patients are the group in which this tension is sharpest. For nurses, the program expanded roles in discharge planning and follow-up but also added documentation and pressure to shorten stays.
On the phone two days after discharge, a nurse can feel this pressure directly. A transition nurse who calls a heart failure patient two days after discharge and hears that his weight is up four pounds faces a choice between adjusting diuretics by phone, arranging a same-day clinic visit or sending him to the emergency department, and the program's incentives should never be the deciding factor. Clear clinical protocols, written by nurses and physicians together, protect both the patient and the nurse from that pressure.
Recommendations
For a hospital, the analysis supports investing in transitions that help patients, such as nurse-led follow-up calls within 48 hours and early clinic visits, while monitoring deaths after discharge alongside readmissions, so that success on one measure does not hide harm on another. Patients with heart failure who return should be readmitted when clinically indicated, regardless of the penalty. For the program, policymakers could pair readmission measures with post-discharge mortality, continue adjusting for social risk and consider rewarding improvement rather than only penalizing high rates.
Conclusion
The Hospital Readmissions Reduction Program achieved its stated goal: readmissions fell, and relabeling as observation does not appear to explain the decline. Still, two large studies saw more deaths among patients sent home with heart failure, and hospitals serving the poorest patients paid more than their share of the fines. A balanced analysis credits the program's success, takes the possible harm seriously and recommends measuring mortality alongside readmissions.
References
Gupta, A., Allen, L. A., Bhatt, D. L., Cox, M., DeVore, A. D., Heidenreich, P. A., Hernandez, A. F., Peterson, E. D., Matsouaka, R. A., Yancy, C. W., & Fonarow, G. C. (2018). Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure. JAMA Cardiology, 3(1), 44-53. https://doi.org/10.1001/jamacardio.2017.4265
Wadhera, R. K., Joynt Maddox, K. E., Wasfy, J. H., Haneuse, S., Shen, C., & Yeh, R. W. (2018). Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA, 320(24), 2542-2552. https://doi.org/10.1001/jama.2018.19232
Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine, 374(16), 1543-1551. https://doi.org/10.1056/NEJMsa1513024
NUR 8100 Module 3 instructions, in plain terms
TESU's NUR-8100 description lists quality measurement, financing and the view from inside organizations; lacking a public syllabus, this third module takes up a Medicare payment rule meant to raise quality. You will likely be asked to explain the mechanics of a payment program, weigh what it was meant to do against what else it did, look at it as a hospital would and propose changes for the hospital and for the rule. Some classrooms assign the Hospital Value-Based Purchasing Program, the Merit-based Incentive Payment System or a state program instead. Check the directions. Look for evidence of unintended consequences, since payment policies change behavior in more ways than their designers intended. Read at least two studies that use different data, because agreement between them strengthens your conclusion.
Inside the NUR 8100 Module 3 example
The paper begins with the old incentive under which readmissions generated payment, then explains the program's mechanics, conditions, penalty cap and peer grouping. A section on readmissions uses an interrupted time series of 3,387 hospitals and addresses the observation stay concern. A section on mortality reports the 8.3 million hospitalization study and its limits. A three-row table balances success against possible harm. The organization perspective section covers transition investments and safety-net hospitals, and a shorter section covers patients and nurses. Recommendations are given for a hospital and for the program, followed by a conclusion that credits the success and weighs the harm. Two studies with different data sources are used for the harm, so the concern does not rest on one analysis.
NUR 8100 Module 3 rubric: what earns full marks
Quality and payment policy analyses are graded on an accurate explanation of how the policy works, balanced use of evidence on intended and unintended effects and a clear analysis from the assigned perspective. Mentors look for recognition of study design limits, especially when observational studies find harm. Doctoral work should ask who bears a penalty, and safety-net hospitals are the obvious test. Recommendations should be specific for both the organization and policymakers. Journal sources, cited in APA, bring the last marks. A table that places benefits and harms side by side is often credited because it shows that both were considered. Graders also notice when the student explains why observational findings of harm still deserve action.
Common NUR 8100 Module 3 mistakes, and how to avoid them
The most common weakness is reporting that readmissions fell and stopping there. Look for evidence of what else changed, including mortality and observation stays. Another error is treating an observational association as proof of harm; say what the study can and cannot show. Students also forget the policy's mechanics, such as which conditions count and how penalties are calculated. Address safety-net hospitals and social risk. Make recommendations concrete, such as follow-up within 48 hours, rather than general calls for better transitions. Cite every source you list, and report each study's population and years. Mentors reward an analysis that shows the program working and failing at the same time. The desk can analyze the payment policy your NUR-8100 classroom assigns, with the first draft free.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 8100 Module 3 questions, answered
Where can I find a free NUR 8100 Module 3 sample paper?
Above, in full. It analyzes the Hospital Readmissions Reduction Program, from falling readmissions to concerns about deaths after discharge.
What is the Hospital Readmissions Reduction Program?
The 2010 reform's penalty program: Medicare trims a hospital's base payments, by as much as 3 percent, when its one-month return rate for listed diagnoses runs above what its case mix predicts.
Did readmissions fall under the program?
Yes. Across more than three thousand hospitals the penalized conditions came back less often by 2015, with the steepest fall right after the law passed in 2010.
Did the readmission penalty increase deaths?
One Medicare study of over eight million stays linked the program to more deaths soon after discharge for heart failure and pneumonia, and a registry study found the same for heart failure; neither proves cause.
Why were safety-net hospitals penalized more?
Poverty, unstable housing and missing rides send their patients back more often whatever the care was like. Medicare answered in 2019 by scoring each hospital only against others that serve as many dual-eligible patients.