C. K. Zogg1,2, J. R. Thumma2, A. M. Ryan2, J. B. Dimick2 1Yale University School Of Medicine,New Haven, CT, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA
Introduction: In FY2015, Medicare began reducing payments to hospitals with high adverse-event rates. Termed the Hospital Acquired Condition (HAC) Reduction Program, concern has been expressed that HAC penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. The objective of this study was to examine the extent to which a hospital’s percentage of minority patients associates with FY2017 a) overall/domain-specific HAC scores and b) HAC penalty receipt. Differences in socioeconomic status (SES) and hospital receipt of DSH payments (a marker of safety-net status) were also assessed.
Methods: Older adult (≥65y) inpatients presenting for eight common surgical conditions were identified using 2013-2014 100% Medicare fee-for-service claims. Records were matched to risk-adjusted FY2017 HAC scores/penalties and hospital-level data from Medicare Hospital Impact files and the AHA Annual Survey Database. Differences were compared using multilevel logistic regression and calculation of absolute percentage-point change. Restricted analyses addressed the possibility that marginal changes among the most vulnerable (likely to be penalized) institutions could be driving the differences observed.
Results: As a hospital’s percentage of minority patients increased, climbing from 1.0 to 25.1%, average HAC scores also increased, rising from 5.8 to 6.3 (higher values indicate worse scores). Increases in penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of minority-serving extent (45.7 vs 36.7%; OR[95%CI]: 1.45[1.42-1.47])—absolute difference +8.9% (Figure). Similar patterns were seen for safety-net (1.44[1.42-1.47]) and low SES-serving (1.38[1.35-1.40]) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated differences in penalties when limiting hospitals to those at highest risk (more residents-to-beds, more severe)—absolute differences +13.9% and +20.5%. Restriction to high operative volume, in contrast, reduced the penalty difference—absolute difference +6.6%.
Conclusion: Minority-serving hospitals are being disproportionately affected by the HAC Reduction Program. While scores followed a stepwise increase, disparities in penalty allocation were isolated to hospitals with the largest minority-serving extent—a finding which became more pronounced among hospitals with an already heightened risk of penalty receipt. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions in order to ensure that disparities do not increase.
