Liu Michael, Sandhu Sahil, Joynt Maddox Karen E, Wadhera Rishi K
Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Harvard Medical School, Boston, Massachusetts.
JAMA. 2024 Apr 23;331(16):1387-1396. doi: 10.1001/jama.2024.2440.
Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown.
To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments.
Hospital Value-Based Purchasing program HEA.
Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics.
Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively.
Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.
医疗保险的医院价值导向型采购（HVBP）计划将从2026财年开始，对同时符合医疗保险和医疗补助资格的患者比例较高且提供高质量医疗服务的医院进行健康公平性调整（HEA）。然而，哪些医院将从这一政策变化中获益最大以及获益程度尚不清楚。
估计健康公平性调整后医院绩效的潜在变化，并研究与获得增加支付相关的医院患者构成、结构和地理特征。
设计、设置和参与者：这项横断面研究分析了2021财年参与HVBP计划的所有2676家医院。将公开可用的项目绩效和医院特征数据与每家医院所有符合双重资格受益人的住院医保理赔数据相链接，以计算健康公平性调整点数和HVBP支付调整。
医院价值导向型采购计划的健康公平性调整。
HVBP奖金或惩罚状态的重新分类以及各医院特征的支付调整变化。
在2021财年参与HVBP计划的2676家医院中，1470家（54.9%）获得奖金，1206家（45.1%）受到惩罚。健康公平性调整后，102家医院（6.9%）从奖金状态重新分类为惩罚状态，而119家医院（9.9%）从惩罚状态重新分类为奖金状态。在医院层面，健康公平性调整后，HVBP支付调整的平均值（标准差）减少了4534美元（90033美元），最大减少额为1014276美元，最大增加额为1523765美元。在总体层面，支付调整的净正向变化在安全网医院中最大（28971708美元），在照顾黑人患者比例较高的医院中也较大（15468445美元）。与非安全网医院相比，安全网医院支付调整增加的可能性显著更高（683家医院中的574家[84.0%] 对1993家医院中的709家[35.6%]；调整率比[ARR]，2.04 [95%置信区间，1.89 - 2.20]），与非高比例黑人医院相比，高比例黑人医院也是如此（523家医院中的396家[75.7%] 对2153家医院中的887家[41.2%]；ARR，1.40 [95%置信区间，1.29 - 1.51]）。农村医院（612家医院中的374家[61.1%] 对2064家医院中的909家[44.0%]；ARR，1.44 [95%置信区间，1.30 - 1.58]），以及位于南部的医院（1040家医院中的598家[57.5%] 对439家医院中的192家[43.7%]；ARR，1.25 [95%置信区间，1.10 - 1.42]）和处于医疗补助扩展州的医院（1651家医院中的801家[48.5%] 对1025家医院中的482家[47.0%]；ARR，1.16 [95%置信区间，1.06 - 1.28]），与它们的城市、东北部和非医疗补助扩展州的同行相比，在健康公平性调整后也更有可能经历支付调整增加。
医疗保险在HVBP计划中实施健康公平性调整将显著重新分类医院绩效并重新分配计划支付，安全网医院和高比例黑人医院将从这一政策变化中获益最大。这些发现表明，健康公平性调整是确保基于价值的支付计划更加公平的重要策略。
