Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.
Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts.
JAMA Netw Open. 2019 Apr 5;2(4):e192987. doi: 10.1001/jamanetworkopen.2019.2987.
Since the introduction of the Hospital Readmission Reduction Program (HRRP), readmission penalties have been applied disproportionately to institutions that serve low-income populations. To address this concern, the US Centers for Medicare & Medicaid introduced a new, stratified payment adjustment method in fiscal year (FY; October 1 to September 30) 2019.
To determine whether the introduction of a new, stratified payment adjustment method was associated with an alteration in the distribution of penalties among hospitals included in the HRRP.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cross-sectional study, US hospitals included in the HRRP for FY 2018 and FY 2019 were identified. Penalty status of participating hospitals for FY 2019 was determined based on nonstratified HRRP methods and the new, stratified payment adjustment method. Hospitals caring for the highest proportion of patients enrolled in both Medicare and Medicaid based on quintile were assigned to the low-socioeconomic status (SES) group.
Nonstratified and stratified Centers for Medicare & Medicaid payment adjustment methods.
Net reclassification of penalties among all hospitals and hospitals in the low-SES group, in states participating in Medicaid expansion, and for 4 targeted medical conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia).
Penalty status by both payment adjustment methods (nonstratified and stratified) was available for 3173 hospitals. For FY 2019, the new, stratified payment method was associated with penalties for 75.04% of hospitals (2381 of 3173), while the old, nonstratified method was associated with penalties for 79.07% (2509 hospitals), resulting in a net down-classification in penalty status for all hospitals by 4.03 percentage points (95% CI, 2.95-5.11; P < .001). For the 634 low-SES hospitals in the sample, the new method was associated with penalties for 77.60% of hospitals (492 of 634), while the old method was associated with penalties for 91.64% (581 hospitals), resulting in a net down-classification in penalty status of 14.04 percentage points (95% CI, 11.18-16.90; P < .001). Among hospitals that were not low SES (quintiles 1-4), the new payment method was associated with a small decrease in penalty status (1928 vs 1889; net down-classification, 1.54 percentage points; 95% CI, 0.38-2.69; P = .01). Among target medical conditions, the greatest reduction in penalties was observed among cardiovascular conditions (net down-classification, 6.18 percentage points; 95% CI, 4.96-7.39; P < .001).
The new, stratified payment adjustment method for the HRRP was associated with a reduction in penalties across hospitals included in the program; the greatest reductions were observed among hospitals in the low-SES group, lessening but not eliminating the previously unbalanced penalty burden carried by these hospitals. Additional public policy research efforts are needed to achieve equitable payment adjustment models for all hospitals.
重要性：自医院再入院减少计划（HRRP）推出以来，再入院处罚一直不成比例地适用于为低收入人群服务的机构。为了解决这一问题，美国医疗保险和医疗补助服务中心在 2019 财年（10 月 1 日至 9 月 30 日）引入了一种新的、分层的支付调整方法。
目的：确定引入一种新的、分层的支付调整方法是否会改变 HRRP 中包含的医院的处罚分布。
设计、设置和参与者：在这项回顾性的横截面研究中，确定了 2018 财年和 2019 财年参与 HRRP 的美国医院。根据非分层 HRRP 方法和新的分层支付调整方法，确定参与医院 2019 财年的处罚情况。根据五分位数，为医疗保险和医疗补助计划中登记的患者比例最高的医院分配到低社会经济地位（SES）组。
暴露：非分层和分层的医疗保险和医疗补助支付调整方法。
主要结果和测量：所有医院和低 SES 组医院、参与医疗补助扩大计划的州以及 4 种特定医疗条件（急性心肌梗死、心力衰竭、慢性阻塞性肺疾病和肺炎）的处罚情况的净重新分类。
结果：通过两种支付调整方法（非分层和分层）都可以获得 3173 家医院的处罚情况。对于 2019 财年，新的分层支付方法与 75.04%（2381/3173）的医院的处罚有关，而旧的非分层方法与 79.07%（2509 家医院）的处罚有关，导致所有医院的处罚情况平均下降 4.03 个百分点（95%CI，2.95-5.11；P < .001）。在样本中 634 家低 SES 医院中，新方法与 77.60%（492/634）的医院的处罚有关，而旧方法与 91.64%（581 家医院）的处罚有关，导致处罚情况平均下降 14.04 个百分点（95%CI，11.18-16.90；P < .001）。在非低 SES 医院（1-4 五分位数）中，新的支付方法与处罚情况的轻微下降有关（1928 与 1889；净下降，1.54 个百分点；95%CI，0.38-2.69；P = .01）。在目标医疗条件中，心血管疾病的处罚降幅最大（净下降 6.18 个百分点；95%CI，4.96-7.39；P < .001）。
结论和相关性：HRRP 的新分层支付调整方法与该计划中包含的医院的处罚减少有关；在低 SES 组的医院中，处罚减少幅度最大，减轻了但没有消除这些医院以前承担的不平衡的处罚负担。需要进一步开展公共政策研究工作，为所有医院建立公平的支付调整模式。
