Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.
Behavioral, Social, and Health Education Sciences Division, Rollins School of Public Health, Emory University, Atlanta, Georgia.
JAMA Intern Med. 2021 Mar 1;181(3):330-338. doi: 10.1001/jamainternmed.2020.7386.
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.
To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification.
DESIGN, SETTING, AND PARTICIPANTS: 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.
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.
Penalties in the prestratification vs poststratification schemes.
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.
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.
医院获得性条件减少计划（HACRP）是一个基于价值的支付计划，专注于安全事件。先前的研究发现，该计划不成比例地惩罚安全网医院，这些医院的表现可能更差，不是因为质量较低，而是因为未测量的疾病严重程度。类似的计划，医院再入院减少计划，根据其患者同时参加医疗保险和医疗补助的比例，将医院分为 5 个同行组进行评估，但分层对 HACRP 的影响尚不清楚。
描述 HACRP 惩罚的医院以及分层前后财务惩罚的分布。
设计、设置和参与者：本经济评价使用了公开的 HACRP 绩效和惩罚数据与医院特征和成本报告合并。研究了 2020 财年参与 HACRP 的 3102 家医院（涵盖 2016 年 7 月 1 日至 2018 年 12 月 31 日的数据）。
根据患者双重参保的比例，医院被分为 5 组，而不是对每组中表现最差的四分之一的医院进行惩罚，而是对每组中表现最差的四分之一的医院进行惩罚。
分层前后的惩罚。
本研究确定了 3102 家接受 HACRP 评估的医院。安全网医院在分层前收到了 111333384 美元的罚款，而分层后估计为 79087744 美元，节省了 32245640 美元。分层后不太可能受到惩罚的医院包括安全网医院（分层前有 33.6%受到惩罚，分层后有 24.8%，差异为-8.8 个百分点[pp]，P <.001）、公立医院（34.1%比 30.5%，差异为-3.6 pp，P =.003）、西部医院（26.8%比 23.2%，差异为-3.6 pp，P <.001）、医疗补助扩张州的医院（27.3%比 25.6%，差异为-1.7 pp，P =.003）以及为最多残疾患者提供护理的医院（32.2%比 28.3%，差异为-3.9 pp，P <.001）和来自种族/少数民族背景的患者（35.1%比 31.5%，差异为-3.6 pp，P <.001）。在多变量分析中，安全网地位和治疗病情高度复杂的患者与从受罚状态转变为非受罚状态的几率更高相关。
这项经济评价表明，对医院进行分层将与减少惩罚差距和显著减少安全网医院的惩罚有关。政策制定者应考虑为 HACRP 采用分层。
