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- Title
Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program.
- Authors
Shashikumar, Sukruth A.; Waken, R. J.; Luke, Alina A.; Nerenz, David R.; Joynt Maddox, Karen E.
- Abstract
<bold>Importance: </bold>The Hospital-Acquired Condition Reduction 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.<bold>Objective: </bold>To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification.<bold>Design, Setting, and Participants: </bold>This 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.<bold>Exposures: </bold>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.<bold>Main Outcomes and Measures: </bold>Penalties in the prestratification vs poststratification schemes.<bold>Results: </bold>The 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.<bold>Conclusions and Relevance: </bold>This 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.
- Subjects
UNITED States; MEDICARE; ECONOMIC impact; MEDICAID; HOSPITAL statistics; IATROGENIC diseases; ECONOMICS
- Publication
JAMA Internal Medicine, 2021, Vol 181, Issue 3, p330
- ISSN
2168-6106
- Publication type
journal article
- DOI
10.1001/jamainternmed.2020.7386