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Vulnerable Hospitals, Cancer Surgery Readmissions, and Penalizing Payment Programs

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Key Points

  • The 30-day readmission rates were 14% for safety net hospitals, 13% for high Medicaid hospitals, and 14% for safety net and high Medicaid institutions.
  • Ninety-day readmission rates were 20% for safety net hospitals, 22% for high Medicaid hospitals, and 21% for high Medicaid and safety net hospitals. In contrast, the readmission rates for nonvulnerable hospitals were 11% at 30 days and 17% at 90 days.
  • Patients having cancer operations at vulnerable hospitals were more likely to live in low-income areas (28% vs 17%); have Medicaid (27% vs 5%); and be admitted via the emergency department for their index procedure (15% vs 9%) than those who had their operations at nonvulnerable hospitals.

Readmission rates after complex cancer operations tend to be higher in hospitals that are considered to be vulnerable because they serve as safety nets in their communities or have a high number of Medicaid patients. Reasons for higher readmission rates are highly complex and involve socioeconomic and hospital institutional characteristics. Payment programs that penalize hospitals for high readmission rates without understanding these issues could stress already financially threatened institutions, according to Hong et al, whose new study was published in the Journal of the American College of Surgeons.

HRRP Details

The Medicare Hospital Readmissions Reduction Program (HRRP) in the Affordable Care Act financially penalizes hospitals that have higher-than-expected readmission rates. HRRP currently covers four common medical conditions—pneumonia, heart failure, acute myocardial infarction, and chronic obstructive pulmonary disease (COPD), along with two joint replacement operations (knee and hip). The program will expand in 2017 and begin including coronary artery bypass grafting (CABG) procedures.

While the American College of Surgeons (ACS) has publicly recognized that high readmission rates may reflect lower quality care and lead to unnecessary spending, ACS has emphasized that readmissions may be related to many factors, including the complexity of the medical condition as well as patients' socioeconomic status and compliance. ACS has urged HRRP to take such factors into consideration so hospitals are not penalized because of factors that are beyond their control.

In the present study, researchers found that patient factors were primary drivers of higher readmission rates to vulnerable hospitals after cancer operations. These results further support the need for incorporating socioeconomic variables into the determination of HRRP payments, especially for hospitals that already serve a disproportionate number of disadvantaged patients.

“Patient conditions and hospital infrastructure make vulnerable hospitals prone to higher readmissions from the outset. Policymakers need to be aware of the drivers that lead to higher readmissions at these hospitals so payment penalties do not push financially strained hospitals into further hardship,” said Young Hong, MD, lead study investigator and surgeon at the MedStar-Georgetown Surgical Outcomes Research Center and Georgetown University Medical Center.

Study Findings

The researchers evaluated the care of 110,857 adult patients who had one of seven major or complex cancer procedures between January 1, 2004, and September 30, 2011, in 1 of 355 hospitals in the state of California. The researchers compared readmission rates for 311 nonvulnerable hospitals, 13 safety net hospitals, 31 high Medicaid institutions, and 5 hospitals that were both safety net and high Medicaid institutions. Patients underwent cancer resection procedures to remove the esophagus, stomach, pancreas, liver, prostate, lung, or kidney.

The 30-day readmission rates were 14% for safety net hospitals, 13% for high Medicaid hospitals, and 14% for safety net and high Medicaid institutions. Ninety-day readmission rates were 20% for safety net hospitals, 22% for high Medicaid hospitals, and 21% for high Medicaid and safety net hospitals. In contrast, the readmission rates for nonvulnerable hospitals were 11% at 30 days and 17% at 90 days.

Patients having cancer operations at vulnerable hospitals were more likely to live in low-income areas (28% vs 17%); have Medicaid (27% vs 5%); and be admitted via the emergency department for their index procedure (15% vs 9%) than those who had their operations at nonvulnerable hospitals.

Patient cohorts differed in various types of vulnerable hospitals. The proportion of Hispanic patients was much higher (41%) at high Medicaid hospitals than at safety net (24%) or high Medicaid and safety net institutions (25%). High Medicaid and safety net institutions had a higher percentage of Medicaid patients (41%) than either of the other categories of vulnerable hospitals (27% for safety net hospitals; 24% for high Medicaid hospitals).

The vast majority of safety net and high Medicaid plus safety net institutions were teaching centers (85% and 100%, respectively), while 47% of high Medicaid hospitals had teaching programs.

“This study showed that the reasons behind higher readmissions may depend on the type of vulnerable hospital, given their varying patient populations and hospital characteristics,” said Chaoyi Zheng, MS, statistician for the study group.

Findings from this study reinforce ACS's position that measures for determining financial penalties associated with hospital readmissions should focus on patient subgroups and socioeconomic factors.

“Different hospitals have different patient mixes, and if that is not factored in, HRRP reductions in payment may further marginalize financially vulnerable hospitals,” said corresponding study author Waddah B. Al-Refaie, MD, FACS, Chief of Surgical Oncology at MedStar Georgetown University Hospital.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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