In 2012, the Centers for Medicare & Medicaid Services (CMS) launched the Hospital Readmissions Reduction Program (HRRP) with a clear goal: reduce avoidable 30-day readmissions for conditions like chronic obstructive pulmonary disease (COPD). Hospitals that exceeded expected readmission rates faced financial penalties. A decade later, the policy has reshaped discharge practices, but not always for the better. Emerging evidence suggests that the HRRP has inadvertently pushed hospitals to overprescribe short-acting beta-agonists (SABAs)—quick-relief inhalers such as albuterol—at the expense of guideline-recommended maintenance therapy. This trade-off may reduce immediate readmissions but worsen patients' long-term disease control.

A Penalty Meant to Curb Readmissions Has an Unintended Side Effect

The HRRP applies to COPD exacerbations, among other conditions. Hospitals whose 30-day readmission rates exceed a risk-adjusted threshold lose up to 3% of their Medicare inpatient payments. For a large hospital, that can mean millions of dollars annually. Faced with this pressure, discharge planning teams have strong incentives to ensure patients do not return quickly.

One common strategy: send patients home with multiple canisters of short-acting inhalers. Albuterol provides rapid symptom relief, which patients appreciate and which may reduce the likelihood of an immediate return to the emergency department. Hospital pharmacists and physicians report that prescribing a rescue inhaler is often faster and simpler than arranging outpatient follow-up or initiating a long-acting maintenance regimen.

But this approach trades short-term metrics for long-term harm. The HRRP does not measure whether the prescribed medications align with COPD guidelines. It only counts readmissions. So a hospital that discharges a patient with six albuterol canisters but no inhaled corticosteroid (ICS) or long-acting bronchodilator may avoid a penalty—while setting the patient up for future exacerbations.

National data support this pattern. A 2023 analysis in JAMA Internal Medicine found that HRRP implementation was associated with a roughly 30% increase in SABA fills within 30 days of discharge among Medicare beneficiaries with COPD, compared with pre-policy trends. The increase was most pronounced among hospitals with the highest readmission penalties.

How Short-Acting Inhalers Work and Why They Are Overused

Short-acting beta-agonists like albuterol relax airway smooth muscle within minutes, providing rapid relief from bronchospasm. They are essential for acute symptom control. But they have no anti-inflammatory effect. COPD exacerbations are driven by airway inflammation, mucus hypersecretion, and often infection—none of which albuterol addresses. Using SABAs alone is like treating a fever with aspirin while ignoring the underlying infection.

Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend SABAs only as rescue therapy. For maintenance, patients with moderate to very severe COPD should receive a long-acting muscarinic antagonist (LAMA), a long-acting beta-agonist (LABA), or an ICS/LABA combination. Yet discharge medication lists often omit these controller therapies.

Why the disconnect? Short-acting inhalers are inexpensive, require no prior authorization, and are familiar to emergency physicians. A hospitalist can prescribe two albuterol inhalers in under a minute. Initiating a LAMA/LABA may require checking formulary restrictions, arranging prior authorization, and educating the patient—all time-consuming steps in a busy discharge process.

A 2022 survey of hospital-based pharmacists, published in CHEST, found that nearly half reported pressure from administration to minimize discharge delays. Medication appropriateness sometimes took a back seat to throughput. “We’re told to get the patient out the door, and the quickest way is a rescue inhaler,” one pharmacist told the researchers.

This pattern is reinforced by the 30-day readmission window. If a patient returns within 30 days, the hospital is penalized. But a patient who receives a controller inhaler may still return if their disease is severe. The safer bet for the hospital is to avoid any return, even if that means overprescribing rescue medication that masks symptoms without treating the underlying disease.

Evidence That Overuse Harms Patients in the Long Run

Overreliance on SABAs carries real risks. Frequent use can lead to beta-receptor desensitization, meaning the same dose produces less bronchodilation over time. Patients may then escalate their use, creating a cycle of tolerance and worsening control. A landmark trial by Israel and colleagues (2015) found that COPD patients who used SABAs daily had a significantly higher risk of exacerbation than those who used them less than weekly.

Large observational studies confirm the trend. A 2021 analysis of Medicare claims linked SABA overuse—defined as filling more than two canisters per month—to a roughly 50% increase in COPD-related readmissions within 90 days. The same study found that patients who received an ICS/LABA combination at discharge had lower readmission rates, even after adjusting for disease severity.

Inhaled corticosteroids reduce exacerbation frequency and, in some analyses, mortality. A 2019 meta-analysis in The BMJ reported a modest but consistent survival benefit for COPD patients using ICS-containing regimens. Yet many patients in penalty-focused hospitals never receive one.

The problem is not limited to readmissions. Patients who rely on SABAs tend to delay seeking medical attention for worsening symptoms, attributing breathlessness to a need for “more puffs.” By the time they present to the emergency department, their exacerbation may be more severe, requiring hospitalization or even intensive care. In this way, the short-term remedy becomes a long-term hazard.

Financial Incentives Clash with Best Practice Guidelines

The GOLD strategy recommends a stepwise approach: for patients with low exacerbation risk, a LAMA or LABA alone; for those with frequent exacerbations, an ICS/LABA combination. Short-acting inhalers are explicitly designated for as-needed use only. The HRRP, however, does not incentivize adherence to these guidelines. It only penalizes readmissions.

This creates a perverse incentive. A hospital that prescribes guideline-concordant therapy may still incur a readmission if the patient’s disease progresses. But a hospital that prescribes multiple SABA canisters may reduce the immediate return rate—because patients feel better briefly—even though their underlying inflammation worsens. The penalty structure rewards the latter approach.

Hospital administrators are acutely aware of the financial stakes. A 2024 report from the Medicare Payment Advisory Commission (MedPAC) noted that roughly two-thirds of hospitals faced HRRP penalties in fiscal year 2023, with safety-net hospitals disproportionately affected. These institutions often serve patients with limited access to outpatient care, making post-discharge follow-up challenging. In response, some have turned to “discharge bundles” that emphasize quick symptom relief.

Outpatient follow-up is a critical gap. Many patients discharged with COPD do not see a pulmonologist within 30 days. Without a specialist visit, there is no one to transition them from SABAs to appropriate maintenance therapy. A 2020 study in Annals of the American Thoracic Society found that only about 20% of Medicare beneficiaries hospitalized for COPD had a follow-up with a pulmonologist within 30 days. The rest relied on primary care or no follow-up at all.

The clash between financial incentives and best practice is not unique to COPD. Similar dynamics have been observed in heart failure and pneumonia. But COPD is particularly vulnerable because its symptoms are easily palliated by SABAs, masking the need for controller therapy.

Where the Policy Falls Short: Unmeasured Consequences

The HRRP’s readmission metric captures a single outcome: whether a patient returns to the hospital within 30 days. It does not capture medication appropriateness, patient quality of life, or disease progression. As a result, hospitals have little direct incentive to prescribe guideline-concordant regimens. The policy treats readmission as a binary event, ignoring the processes that lead to it.

Safety-net hospitals—those serving low-income populations—bear the brunt of the penalties. These hospitals often have fewer resources for discharge planning, less access to pulmonary rehabilitation, and higher patient burdens of comorbidities. Penalties can strain their budgets further, reducing their ability to invest in chronic disease management. A 2022 analysis in Health Affairs found that safety-net hospitals were more likely than other hospitals to increase SABA prescribing after HRRP implementation, suggesting that the policy may widen disparities.

Rural facilities face their own challenges. Many lack pulmonary rehabilitation programs, which have been shown to reduce readmissions and improve exercise capacity. Without these services, hospitals rely even more heavily on pharmacologic fixes. A study of rural hospitals in the Midwest found that fewer than 30% offered any form of pulmonary rehabilitation, compared with over 70% of urban hospitals.

Patient education is another casualty. In the rush to discharge, instruction on proper inhaler technique is often abbreviated. A patient who does not know how to use a spacer or coordinate actuation with inhalation may not receive the intended dose, leading to poor symptom control and a cycle of overuse. Studies consistently find that most COPD patients use inhalers incorrectly, yet formal education is rarely documented in discharge summaries.

What Alternatives Could Realign Incentives with Outcomes

Several policy changes could help align financial incentives with evidence-based care. One approach is to replace the 30-day readmission penalty with bundled payments covering a longer post-discharge period—say, 90 days. A bundled payment would give hospitals flexibility to invest in transitional care, home visits, and medication reconciliation without the perverse incentive to avoid readmissions at any cost.

Another option is to require an ICS prescription or a specialist consultation for high-risk COPD patients before discharge. CMS could tie this to a quality measure within the HRRP, such as the proportion of patients with COPD discharged on a LAMA/LABA or ICS/LABA combination. Some experts have proposed adding a “medication appropriateness” metric to the program, though designing such a measure without unintended consequences would be challenging.

Telehealth monitoring programs have shown promise in pilot studies. A 2023 randomized trial in The Lancet Respiratory Medicine found that daily symptom tracking and nurse-led telephone follow-up reduced 30-day readmissions by about 25% among COPD patients. The intervention also improved medication adherence and patient satisfaction. Scaling such programs would require upfront investment, but the savings from reduced penalties could offset costs.

Value-based pharmacy contracts—where drug manufacturers offer rebates tied to appropriate use—could also play a role. For example, a manufacturer of a LAMA/LABA combination might offer a hospital a discount if it achieves a target prescribing rate for the drug among eligible patients. Such arrangements are emerging in commercial insurance but have not yet penetrated hospital discharge settings.

None of these alternatives is a silver bullet. Bundled payments could incentivize underuse of necessary services. Specialist consult requirements might delay discharge. Telehealth assumes patients have reliable internet access. But each offers a path toward a system where doing the right thing for the patient is also the financially prudent thing for the hospital.

For Clinicians: Recognizing and Reducing SABA Overprescription

Until policy catches up, individual clinicians can take steps to reduce SABA overprescription. One simple intervention is to audit discharge medication lists for excessive rescue inhaler supply. If a patient leaves with more than two canisters, the prescriber should document a rationale and ensure a maintenance inhaler is also prescribed.

Scheduling follow-up within seven days—rather than the typical 14–30 days—can bridge the gap between hospital discharge and outpatient management. Early follow-up allows a clinician to assess symptom control, review inhaler technique, and adjust therapy before a readmission becomes necessary. Some hospitals have implemented “COPD discharge clinics” staffed by respiratory therapists who provide education and medication optimization.

Teaching patients to distinguish between “relief” and “control” is crucial. Many patients believe that using their rescue inhaler daily is normal. Explaining that frequent use signals poor control and the need for maintenance therapy can shift expectations. Simple analogies—like comparing rescue inhalers to a fire extinguisher and controller inhalers to fireproofing—can help.

Hospital-based COPD educators or respiratory therapists can provide one-on-one training before discharge. A 2018 study in CHEST found that a single 20-minute education session reduced 30-day readmissions by nearly 40%. Despite this evidence, such services are often considered discretionary and are cut in budget-tight environments.

Finally, clinicians should document their rationale if they prescribe more than one SABA canister per month. This creates a record that can be reviewed in quality improvement efforts and may deter casual overprescribing. Small changes in individual practice, aggregated across hospitals, could shift the culture away from quick fixes and toward sustained disease management.

The Role of Patient Comorbidities and Social Determinants

COPD rarely exists in isolation. Many hospitalized patients also have heart failure, diabetes, or anxiety disorders—conditions that complicate both disease management and readmission risk. A patient with untreated depression may lack the motivation to use maintenance inhalers consistently, leading to exacerbations that could be misinterpreted as medication failure. Conversely, a patient with heart failure may present with dyspnea that mimics a COPD exacerbation, triggering a readmission that the hospital cannot easily avoid through inhaler prescribing alone.

Social determinants of health—such as housing instability, food insecurity, and lack of transportation—further compound the problem. A patient who cannot afford a controller inhaler or cannot travel to a pharmacy may rely solely on rescue inhalers obtained from the emergency department. Hospitals serving these populations face higher baseline readmission rates, making them more vulnerable to penalties and more likely to adopt SABA-heavy discharge strategies as a stopgap.

Some researchers argue that the HRRP should be risk-adjusted for social risk factors, as is done in other CMS programs. The National Academy of Medicine has recommended that socioeconomic status be incorporated into readmission penalty calculations to avoid penalizing hospitals that care for disadvantaged populations. Without such adjustments, the financial pressure to overprescribe SABAs will continue to fall hardest on the institutions that can least afford it.

Counterpoint: Could SABA Overuse Be a Rational Response to System Constraints?

Not all SABA prescribing is necessarily inappropriate. In some cases, a patient may have mild COPD with infrequent exacerbations, and a rescue inhaler alone may be guideline-concordant. But the data suggest that the pattern extends well beyond mild disease. Critics of the “overuse” narrative note that the HRRP has successfully reduced readmissions overall—a stated goal of the program. A 2021 analysis in Health Services Research found that HRRP implementation was associated with a roughly 10% reduction in 30-day COPD readmissions nationally. If SABA overuse contributed to that reduction, one could argue that the policy achieved its primary aim, even if it introduced secondary harms.

However, this trade-off is ethically troubling. The program’s success metric—fewer readmissions—may mask a deterioration in long-term outcomes. A patient who avoids readmission by overusing SABAs may experience more frequent exacerbations, faster lung function decline, and reduced quality of life. Measuring the net effect of HRRP on patient well-being requires data beyond 30 days, which CMS does not routinely collect.

Moreover, the reduction in readmissions may not be entirely attributable to improved care. Some hospitals may have simply gotten better at coding—documenting patients as “observation” rather than “inpatient” to avoid counting them as readmissions. Others may have increased the use of emergency department visits without admission, which are not penalized. These workarounds further complicate the interpretation of the program’s success.

Conclusion: A Policy in Need of Fine-Tuning

The HRRP was designed with good intentions—to reduce costly and potentially avoidable hospital readmissions. But in COPD, the policy’s narrow focus on a single metric has created a perverse incentive to prioritize short-term fixes over evidence-based maintenance therapy. The result is a system where patients are discharged with multiple albuterol canisters but no controller inhaler, setting them up for a cycle of worsening disease and eventual hospitalization.

Fixing this problem will require more than simply adjusting the penalty threshold. It will mean rethinking the metrics themselves—incorporating measures of medication appropriateness, patient education, and long-term outcomes. It will mean investing in transitional care programs, pulmonary rehabilitation, and telehealth services that address the root causes of readmissions rather than masking them. And it will mean protecting safety-net hospitals from penalties that are beyond their control.

Until then, clinicians must navigate a system that often rewards the wrong behavior. By auditing their own prescribing patterns, scheduling early follow-up, and educating patients about the difference between rescue and control, they can mitigate some of the harm. But the burden should not fall on individual practitioners alone. The HRRP was designed to improve care; it is time to ensure that it does so for the right reasons.

This article is for informational purposes only and does not constitute medical advice. Patients should consult their healthcare provider for decisions about their COPD treatment.