The proportion of hospitals that have a high proportion of Black patients compared with other hospitals that were penalized by 0, 1, 2, or all 3 Centers for Medicare & Medicaid Services’ hospital value-based programs (Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, Hospital-Acquired Condition Reduction Program) in fiscal year 2019. Hospitals that participated in all 3 programs were included in the analysis. Overall, 127 of 542 high-proportion Black hospitals and 275 of 2239 other hospitals were penalized by all 3 programs (23.4% vs 12.3%; P < .001). In contrast, 17 of 542 high-proportion Black hospitals and 186 of 2239 other hospitals received no penalties (3.1% vs 8.3%; P < .001)
eAppendix. Hospital Value-Based Programs and Hospital Characteristics
Customize your JAMA Network experience by selecting one or more topics from the list below.
Aggarwal R, Hammond JG, Joynt Maddox KE, Yeh RW, Wadhera RK. Association Between the Proportion of Black Patients Cared for at Hospitals and Financial Penalties Under Value-Based Payment Programs. JAMA. 2021;325(12):1219–1221. doi:10.1001/jama.2021.0026
Over the last decade, the Centers for Medicare & Medicaid Services (CMS) has implemented national value-based payment programs that aim to incentivize hospitals to deliver higher quality of care. Black adults face systemic barriers in health care access and often receive care at a limited set of underresourced hospitals.1 Although recent changes have been made to some value-based programs to reduce the burden of penalties on safety-net hospitals that serve low-income patients,2-4 whether these initiatives disparately affect hospitals that care for a high proportion of Black patients remains unclear.
Therefore, we evaluated whether hospitals that care for a high proportion of Black patients are more likely than other hospitals to be penalized by value-based programs.
We identified all hospitals that participated in the Hospital Value-Based Purchasing Program (HVBP), Hospital Readmission Reduction Program (HRRP), or Hospital-Acquired Condition Reduction Program (HACRP) in fiscal year 2019 (eAppendix in the Supplement).3 To identify hospitals’ penalty-bonus status and the magnitude of these payment adjustments under each program, we used CMS Hospital Compare. We determined the proportion of Medicare hospitalizations for Black patients using MedPAR files (2015-2018)—institutions in the highest quintile were categorized as high-proportion Black hospitals. The American Hospital Association and CMS Impact Files (2018) were used to determine hospitals’ characteristics and safety-net status (eAppendix in the Supplement).
We calculated the proportion of high-proportion Black hospitals and other hospitals that received a penalty (or bonus) under each value-based payment program. We then determined the adjusted difference between these proportions using multivariable logistic regression, adjusting for hospital characteristics (bed size, teaching status, urban vs rural) and safety-net status. The mean payment adjustment was also determined. Comparisons were performed using 2-sided t tests or χ2 tests. A 2-sided P < .05 defined statistical significance. Analyses were performed using R version 3.5.2. Institutional review board approval was not required by Beth Israel Deaconess Medical Center because the study used publicly available data.
There were 3288 hospitals that received a payment adjustment in at least 1 value-based program (HVBP, 2786; HACRP, 3227; HRRP, 3173) in fiscal year 2019. The 658 hospitals classified as high-proportion Black accounted for 59.3% of all Medicare discharges for Black adults. High-proportion Black hospitals compared with other hospitals were more likely to be large (≥400 beds; 24.9% vs 11.7%; P < .001), teaching institutions (58.5% vs 42.8%; P < .001), urban (81.2% vs 72.3%; P < .001), and safety-net institutions (48.0% vs 18.9%; P < .001).
After adjustment for hospital characteristics, high-proportion Black hospitals were more likely than other hospitals to be penalized by the HVBP (55.7% vs 41.3%; adjusted difference, 8.0%; 95% CI, 2.9%-13.2%; P = .002) and less likely to receive a bonus (44.3% vs 58.7%; adjusted difference, −8.0%; 95% CI, −13.2% to −2.9%; P = .002) (Table). The overall mean payment adjustment differed between high-proportion Black hospitals and other hospitals (−0.02% vs 0.21%; P < .001). High-proportion Black hospitals were also more likely to be penalized by the HACRP (31.5% vs 22.9%; adjusted difference, 9.5%; 95% CI, 5.3%-13.8%; P < .001) and the HRRP (87.7% vs 80.5%; adjusted difference, 4.8%; 95% CI, 1.1%-8.5%; P = .01). The overall mean payment adjustment under the HRRP was similar for high-proportion Black hospitals and other hospitals (−0.57% vs −0.58%; P = .71). High-proportion Black hospitals were more likely to be penalized by all 3 programs (23.4% vs 12.3%; P < .001) (Figure).
Hospitals that care for a high proportion of Black adults were penalized more frequently by CMS value-based programs than other hospitals in 2019, even after accounting for safety-net status. These institutions were also more likely to receive penalties from all 3 federal programs.
Black individuals face structural and systemic barriers in access to high-quality care, in part because of redlining and other policies that have historically restricted Black persons to lower-income communities.5 High-proportion Black hospitals are more likely to be underresourced and have lower operating margins.1 If value-based programs unintentionally result in disparate penalties being imposed on these institutions, their ability to improve care may be hampered and racial disparities in outcomes widened.6
A limitation of this study is that high-proportion Black hospitals were defined using Medicare hospitalizations.
To promote equity, policy makers could consider modifying value-based programs to alleviate penalties on high-proportion Black hospitals.
Accepted for Publication: January 1, 2021.
Corresponding Author: Rishi K. Wadhera, MD, MPP, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, 375 Longwood Ave, Fourth Floor, Boston, MA 02215 (firstname.lastname@example.org).
Author Contributions: Drs Aggarwal and Wadhera had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Aggarwal, Wadhera.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Aggarwal, Wadhera.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Aggarwal, Wadhera.
Obtained funding: Wadhera.
Administrative, technical, or material support: Hammond.
Conflict of Interest Disclosures: Dr Joynt Maddox reported receiving grants from the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the Commonwealth Fund and performing prior contract work for the US Department of Health and Human Services. Dr Yeh reported receiving research support from the National Heart, Lung, and Blood Institute and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; personal fees from Biosense Webster; and grants and personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic. Dr Wadhera reported serving as a consultant for Regeneron. No other disclosures were reported.
Funding/Support: This study was supported by grant K23HL148525 from the National Heart, Lung, and Blood Institute, National Institutes of Health.
Role of the Funder/Sponsor: The National Heart, Lung, and Blood Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: Dr Joynt Maddox was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Create a personal account or sign in to: