Banerjee Souvik, Paasche-Orlow Michael K, McCormick Danny, Lin Meng-Yun, Hanchate Amresh D
Department of Humanities and Social Sciences, Indian Institute of Technology Bombay, Mumbai, Maharashtra, India.
Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
BMC Health Serv Res. 2022 Mar 15;22(1):338. doi: 10.1186/s12913-022-07741-9.
The Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction penalties on acute care hospitals with higher-than-expected readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. There is concern that hospitals serving large numbers of low-income and uninsured patients (safety-net hospitals) are at greater risk of higher readmissions and penalties, often due to factors that are likely outside the hospital's control. Using publicly reported data, we compared the readmissions performance and penalty experience among safety-net and non-safety-net hospitals.
We used nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. We identified as safety-net hospitals the top quartile of hospitals in terms of the proportion of patients receiving income-based public benefits. Using a quasi-experimental difference-in-differences approach based on the comparison of pre- vs. post-HRRP changes in (risk-adjusted) 30-day readmission rate in safety-net and non-safety-net hospitals, we estimated the change in readmissions rate associated with HRRP. We also compared the penalty frequency among safety-net and non-safety-net hospitals.
Our study cohort included 1915 hospitals, of which 479 were safety-net hospitals. At baseline (2009), safety-net hospitals had a slightly higher readmission rate compared to non-safety net hospitals for all three conditions: AMI, 20.3% vs. 19.8% (p value< 0.001); heart failure, 25.2% vs. 24.2% (p-value< 0.001); pneumonia, 18.7% vs. 18.1% (p-value< 0.001). Beginning in 2012, readmission rates declined similarly in both hospital groups for all three cohorts. Based on difference-in-differences analysis, HRRP was associated with similar change in the readmissions rate in safety-net and non-safety-net hospitals for AMI and heart failure. For the pneumonia cohort, we found a larger reduction (0.23%; p < 0.001) in safety-net hospitals. The frequency of readmissions penalty was higher among safety-net hospitals. The proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net and 59% among non-safety-net hospitals.
Our results lend support to the concerns of disproportionately higher risk of performance-based penalty on safety-net hospitals.
医疗保险和医疗补助服务中心（CMS）于2010年3月设立的医院再入院率降低计划（HRRP），对急性心肌梗死（AMI）、心力衰竭和肺炎再入院率高于预期的急性护理医院实施了支付减少处罚。有人担心，为大量低收入和未参保患者服务的医院（安全网医院）面临更高再入院率和处罚的风险更大，这通常是由于一些可能超出医院控制范围的因素所致。我们利用公开报告的数据，比较了安全网医院和非安全网医院的再入院表现及处罚经历。
我们使用了医疗保险和医疗补助服务中心（CMS）医院比较计划、CMS最终影响规则以及美国医院协会年度调查中2009 - 2016年的全国医院层面数据。我们将接受基于收入的公共福利患者比例处于前四分位数的医院确定为安全网医院。基于安全网医院和非安全网医院（风险调整后的）30天再入院率在HRRP实施前后变化的比较，采用准实验性差异分析方法，我们估计了与HRRP相关的再入院率变化。我们还比较了安全网医院和非安全网医院的处罚频率。
我们的研究队列包括1915家医院，其中479家为安全网医院。在基线期（2009年），对于所有三种病症，安全网医院的再入院率略高于非安全网医院：AMI，20.3%对19.8%（p值<0.001）；心力衰竭，25.2%对24.2%（p值<0.001）；肺炎，18.7%对18.1%（p值<0.001）。从2012年开始，两个医院组中所有三个队列的再入院率均以相似的幅度下降。基于差异分析，HRRP与安全网医院和非安全网医院在AMI和心力衰竭再入院率上的相似变化相关。对于肺炎队列，我们发现安全网医院的下降幅度更大（0.23%；p<0.001）。安全网医院的再入院处罚频率更高。在HRRP实施后的所有四年中，受处罚医院的比例在安全网医院中为72%，在非安全网医院中为59%。
我们的结果支持了对安全网医院因绩效而受到处罚的风险过高的担忧。
