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Study: Hospital Payment Program Not Linked to Higher African-American Death Rate

Healthcare policymakers have long worried that value-based payment programs unfairly penalize hospitals treating many African-American patients, which could worsen health outcomes for this group. But a new study found that one major program was not associated with an increase in death rates for African-American patients 30 days after they were discharged.

The study, published today in JAMA Network Open, analyzed data from the Medicare Hospital Readmission Reduction Program, which penalizes hospitals with high numbers of Medicare patients being readmitted within 30 days after discharge with a heart attack, heart failure or pneumonia. Policy experts have suspected that this program unevenly punishes institutions caring for more vulnerable populations, including racial minorities. They've also feared that hospitals might be incentivized to not give patients the care they need to avoid readmissions.

Investigators wanted to determine whether death rates following discharges increased among African-American and white patients 65 years and older after the payment program started.

"Policies like these can unintentionally take resources away from hospitals that treat patients with more complex needs, but such hospitals face the most challenges getting adequate funding to provide care," said senior author Teryl Nuckols, MD, MSHS, director of the Division of General Internal Medicine in the Cedars-Sinai Department of Medicine. "We were expecting to see some level of harm to African-American patients. The actual results were very surprising."

The investigators looked at data from more than 6 million Medicare patient discharges and mortality rates from 3,263 U.S. hospitals for the first two years after the payment program started (October 2012 to November 2014). They compared that data with projections for mortality rates based on trends prior to the program's start (from January 2007 to March 2010). In addition to measuring how often patients died within 30 days after discharge, investigators also tracked 30-day readmissions during these time periods.

Teryl Nuckols, MD, MSHS
"Our research is a step forward in establishing whether or not these policies are harming patients."
Teryl Nuckols, MD, MSHS

The investigators found no evidence that 30-day post-discharge mortality worsened among African-American patients after implementation of the Medicare Hospital Readmission Reduction Program.

In fact, the study showed that heart attack mortality trends improved among African-American patients. Heart failure mortality trends remained stable for this population despite a significant decline in readmissions. But the study actually saw a small increase in mortality for white heart failure patients.

While investigators did not determine a cause for these unexpected changes in mortality trends, their published study reviews some possibilities. For example, many hospitals have reported enhancing transitional care for discharged patients after the payment program was enacted. Because African-American adults 65 and older often face greater challenges navigating discharge transitions than their white peers, the study points out that quality-improvement interventions at hospitals may have been more effective for African-Americans.

Nuckols suggested that future research could assess the actual interventions hospitals are using to reduce readmissions.

"We don't really know how practices have changed nationwide and whether they differ between patient populations and hospitals," Nuckols said. "But our research is a step forward in establishing whether or not these policies are harming patients."

The study was co-led by José J. Escarce, MD, PhD, at the David Geffen School of Medicine at UCLA, and Peter Huckfeldt, PhD, at the University of Minnesota School of Public Health. Additional co-authors included investigators from the David Geffen School of Medicine at UCLA and the Sol Price School of Public Policy at the University of Southern California. Funding came from the Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services.

DOI: 10.1001/jamanetworkopen.2019.0634