Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program

Abstract

Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown.OBJECTIVE To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. DESIGN, SETTING, AND PARTICIPANTSThis economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied.EXPOSURES Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall. MAIN OUTCOMES AND MEASURESPenalties in the prestratification vs poststratification schemes. RESULTSThe study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status. CONCLUSIONS AND RELEVANCEThis economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.

Care Disruption During COVID-19: a National Survey of Hospital Leaders

“…Additional information on hospital characteristics was obtained from the American Hospital Association Annual Survey for 2019. We followed the Centers for Medicare and Medicaid Services' recent approach 12,13 and considered hospitals in the highest quintile of dual enrollment among Medicare admissions to be safety-net hospitals, 14,15 and those in the highest quintile of the proportion of their Medicare admissions who were identified to be Black or Hispanic to be high-minority hospitals, following a similar convention. 14,16,17…”

Dashboard Design to Identify and Balance Competing Risk of Multiple Hospital-Acquired Conditions

“…Audio recordings from the 1:1 interview from 25 participants were transcribed verbatim and analyzed independently by three members of the research team. Using the framework method of qualitive analysis 20 22 and iterative user-centered informed analysis, 10 19 10 themes emerged from the qualitative analysis of participant feedback ( Table 3 ). Primary takeaways from the thematic analysis revealed that participants learned to navigate the tool quickly moving from day 1 to 3 to evaluate MHACs potentially influenced by the removal of the IUC.…”

“…This framework also accounted for differences in these competing risks across patients with a variety of characteristics, including whether an IUC was present on admission, comorbidities, demographics (age, sex, race/ethnicity, and primary insurance), source of admission, and assessments of fall risk and HAPI risk, all of which are correlated with the risk of HACs. [20][21][22] A binary logistic specification was used for the probability of an event occurring on each patient-day and, given an event occurred on a patient-day, a multinomial logistic specification was used for the probability of each HAC. These logistic specifications provided a flexible empirical framework that accounted for the complex interactions between the timing of the decision to remove or reinsert an IUC and the occurrence of HACs.…”

Equity Implications of Hospital Penalties During 4 Years of the Comprehensive Care for Joint Replacement Model, 2016 to 2019

“…Regional benchmarks in CJR may inadvertently serve an institutionalized function of penalizing the safety-net hospitals. 2 Policy makers should ensure that hospitals receive achievable spending benchmarks to avoid widening disparities in care. By design, CJR did not levy penalties in 2016.…”

“…1 Little is known about how Medicare distributed penalties under these policy changes. Given the disproportionate penalization of safety-net hospitals and hospitals serving Black and Hispanic patients under value-based payment, 2 , 3 understanding trends in their penalization status under CJR has important equity implications as Medicare expands bundled payment.…”