Disproportionate Share Hospital Research Articles

Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt.

To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed. In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. 100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients. A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points. Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.

Comparison of 3 Safety-Net Hospital Definitions and Association With Hospital Characteristics

No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding. To examine characteristics of SNHs as classified under 3 common definitions. This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018. Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes. Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state. The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions. Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.

Refining the Definition of US Safety-Net Hospitals to Improve Population Health

Safety-net hospitals (SNHs) in the United States provide care for individuals and families regardless of their ability to pay.1 Since 1986, SNHs have received supplemental federal compensation through Medicare Disproportionate Share Hospital (DSH) payments. These payments have historically been calculated based on the proportion of hospital days accounted for by Medicare Supplemental Security Income plus Medicaid, non-Medicare inpatient days. The Affordable Care Act (ACA) modified this definition and reduced DSH payments to offset a growing insured, low-income population.2

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center

BackgroundPrior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid. MethodsCharges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc. ResultsDuring 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%. ConclusionsSelf-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission.

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States' overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs' tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population's SDOH.AHCs enjoy broad public support and have an opportunity-and an obligation-to lead in improving the nation's health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.

Hospital value based purchasing scores highly associated with prior year score and organizational characteristics

Objective: Medicare’s Hospital Value Based Purchasing program (HVBP) rewards hospitals which achieve a higher than mean Total Performance Score (TPS). This article investigates the relationship between hospital characteristics and prior year Total Performance Score (TPS) on current year TPS under Medicare’s Hospital Value Based Purchasing (HVBP) program.Methods: Regression analyses are used to investigate the relationship between prior year TPS and organizational characteristics on current year TPS.Results: Regression analyses show that certain geographic locations, smaller bed size, and lower disproportionate share hospital percentage (DSHPCT) lead to a significantly higher TPS in both FY 2015 and FY 2016. Teaching status is associated with higher scores in FY 2015 and lower scores in FY 2016. Furthermore, prior year TPS is a significant predictor of current year TPS.Conclusions: Results suggest HVBP performance is dependent upon organizational characteristics which may have little to do with quality or cost of care. Furthermore, the findings demonstrate that prior year HVBP performance is the strongest predictor of future performance which may impede low performing hospitals from achieving success in future years, despite significant gains in improving cost and quality.

Medicaid Innovations and the Role of Academic Health Centers.

Although they represent less than 8% of all U.S. hospitals, academic health centers (AHCs) deliver almost 40% of the inpatient care for Medicaid beneficiaries. However, because of low Medicaid reimbursement rates, AHCs have had to rely on supplemental funding sources, such as disproportionate share hospital (DSH) payments and upper payment limit (UPL) payments. Recent legislative efforts and changes to payment structures have made these sources vulnerable to severe reductions. For instance, DSH payments are scheduled to be cut by $8 billion by 2021, and UPL payments are a diminishing resource for many states because the program is based on a fee-for-service model and most states are moving to managed care.In this Invited Commentary, the authors argue that cuts to supplemental funding sources would harm AHCs. They advocate instead for restructuring traditional supplemental payments to accommodate novel reimbursement models. They cite Medicaid's Delivery System Reform Incentive Payment program as an example of work to leverage supplemental payments to transform the delivery of care for Medicaid beneficiaries. AHCs should be at the epicenter of such innovations in population health for Medicaid beneficiaries. To that end, the authors encourage AHCs to build new partnerships with community-based primary care physicians and community health centers to balance the specialty composition of their faculty providers to assume the risk for Medicaid beneficiaries and other vulnerable populations.

The U.S. Medicare Disproportionate Share Hospital program and capacity planning

U.S. Medicare's Disproportionate Share Hospital (DSH) program provides financial assistance to hospitals that serve low-income populations. Statutory formulas determine the DSH payments made to hospitals; however, the formulas applied to “large” urban hospitals (at least 100 beds) are more generous than those used for “small” urban hospitals (less than 100 beds). The purpose of this study is to determine if the DSH program's 100-bed threshold influences bed capacity planning. We find that the threshold drives a significant discontinuity in the distribution of urban hospital bed capacities, with hospitals tending to maintain just enough beds to qualify for higher DSH payments. The magnitude of the discontinuity is greatest in hospitals with strong incentives to manage bed capacity; and, compared to government and not-for-profit hospitals, for-profit hospitals are more likely to manage capacity to meet the 100-bed threshold. Our findings highlight the potential for regulatory institutions to have unintended influence on capacity planning decisions.

PHS151 - Impact of Affordable Care Act on Medicare Disproportionate Share Hospital (DSH) Payments

PHS151 - Impact of Affordable Care Act on Medicare Disproportionate Share Hospital (DSH) Payments

Will Hospital Peer Grouping by Patient Socioeconomic Status Fix the Medicare Hospital Readmission Reduction Program or Create New Problems?

In 2016 the U.S. Congress directed the Centers for Medicare & Medicaid Services (CMS) to implement the 21st Century Cures Act to fix a flaw in the Hospital Readmissions Reduction Program (HRRP). One section of the Act is intended to remove bias in calculating penalties for hospitals treating large percentages of low socioeconomic status (SES) patients. A study was conducted to analyze the effect of the introduction of SES hospital peer groups on the number and distribution of the hospitals being penalized. The CMS analysis files for the fiscal year 2017 HRRP final rule and Disproportionate Share Hospital adjustments were used to assign hospital peer groups. The median excess readmission ratios for hospital peer groups were calculated, and the resulting pattern of hospital penalties within peer groups was analyzed. The findings suggest that because CMS assigns individual HRRP penalties on six clinical conditions but proposes to assign hospitals to a single SES peer group based on all admissions, it will ignore substantial differences in the distribution of peer group medians across these conditions. For surgical cases, as expected, hospitals with fewer patients had higher readmission rates, while for medical cases, hospitals with fewer patients had fewer readmissions. These findings may result in distortion of the peer group adjustment intended to correct for SES. Hospital peer groups may create unintended redistributions of penalties through distortion of peer group medians. An observed relationship between lower-volume hospitals and fewer readmissions for medical conditions requires additional research to establish its basis.

Consequences of the 340B Drug Pricing Program

BackgroundThe 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient drugs, increasing the profitability of drug administration. By tying the program eligibility of hospitals to their Disproportionate Share Hospital (DSH) adjustment percentage, which reflects the proportion of hospitalized patients who are low-income, the program is intended to expand resources for underserved populations but provides no direct incentives for hospitals to use financial gains to enhance care for low-income patients.MethodsWe used Medicare claims and a regression-discontinuity design, taking advantage of the threshold for program eligibility among general acute care hospitals (DSH percentage, >11.75%), to isolate the effects of the program on hospital–physician consolidation (i.e., acquisition of physician practices or employment of physicians by hospitals) and on the outpatient administration of parenteral drugs by hospital-owned facilities in three specialties in which parenteral drugs are frequently used. For low-income patients, we also assessed the effects of the program on the provision of care by hospitals and on mortality.ResultsHospital eligibility for the 340B Program was associated with 2.3 more hematologist–oncologists practicing in facilities owned by the hospital, or 230% more hematologist–oncologists than expected in the absence of the program (P=0.02), and with 0.9 (or 900%) more ophthalmologists per hospital (P=0.08) and 0.1 (or 33%) more rheumatologists per hospital (P=0.84). Program eligibility was associated with significantly higher numbers of parenteral drug claims billed by hospitals for Medicare patients in hematology–oncology (90% higher, P=0.001) and ophthalmology (177% higher, P=0.03) but not rheumatology (77% higher, P=0.12). Program eligibility was associated with lower proportions of low-income patients in hematology–oncology and ophthalmology and with no significant differences in hospital provision of safety-net or inpatient care for low-income groups or in mortality among low-income residents of the hospitals’ local service areas.ConclusionsThe 340B Program has been associated with hospital–physician consolidation in hematology–oncology and with more hospital-based administration of parenteral drugs in hematology–oncology and ophthalmology. Financial gains for hospitals have not been associated with clear evidence of expanded care or lower mortality among low-income patients. (Funded by the Agency for Healthcare Research and Quality and others.)

Examining EMTALA in the era of the patient protection and Affordable Care Act.

BackgroundLittle is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA).MethodsWe conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements.ResultsSettlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period.ConclusionsEMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.

Dually Enrolled Beneficiaries Have Higher Episode Costs On The Medicare Spending Per Beneficiary Measure.

Cost measures are a growing part of Medicare's value-based payment programs. Medicare Spending per Beneficiary (MSPB) is the cost measure included in Medicare's Hospital Value-Based Purchasing (VBP) Program. Beneficiaries who are dually enrolled in Medicare and Medicaid are known to have higher spending on care, but it is unknown whether spending on the MSPB measure varies based on dual enrollment and whether this has implications for the performance of safety-net hospitals. We found that after adjustment for comorbidities, dually enrolled beneficiaries had 4.3percent higher spending, which was primarily driven by higher costs in the postacute setting associated with use of institutional postacute care. Hospitals in the highest quintile of the disproportionate share hospital index had poorer performance on the MSPB measure, and were more likely to be penalized under VBP. After adjustment for dual status, differences in MSPB performance between safety-net and non-safety-net hospitals were no longer significant. This suggests that differences in performance between the two types of hospitals were driven at least in part by differences in their patient populations. However, overall VBP payment impacts were largely unchanged after the MSPB measure was adjusted for dual-enrollment status.

Evaluation of Quality Outcomes and HCAHPS Scores between Academic and Non-Academic Hospitals

Academic hospitals make great contributions to healthcare through patient care, research, and teaching, but their patient satisfaction, clinical outcomes, and hospital acquired injury scores may not surpass non-academic hospitals. Because scores in these areas are what constitutes rewards or penalties in the new Hospital Value Based Purchasing program, it is beneficial to analyze these measures for academic hospitals. This analysis compared patient satisfaction scores, 30-day readmission rate, 30-day mortality rate, and hospital acquired injury scores between academic and non-academic hospitals. The individual characteristics (bed size, region, etc.) of each hospital were also compared. The data was retrieved from the Hospital Compare database, the Medicare Impact File, and the Association of American Medical Colleges. Academic hospitals were more likely to be larger, have a higher Disproportionate Share Hospital Patient Percentage and be in an urban location. They performed worse than non- academic hospitals in several individual Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) scores, but academic hospitals performed better in a patient’s willingness to recommend the hospital and their total rating given by patients. Academic hospitals had lower mortality rates but higher 30-day readmission rates, catheter associated urinary tract infection, and pressure sore rates. Overall, academic hospital’s performance in HCAHPS scores, mortality, readmissions, and hospital acquired injuries do not seem to represent their accomplishments in training physicians and research. This may be because of their higher likelihood to care for poor patients and also their resources being spread over patient care, research, and education.

Improved Rates of Immediate Breast Reconstruction at Safety Net Hospitals

Substantial federal resources have been directed toward ensuring the delivery of high-quality care at safety net hospitals. Although disparities in receipt of breast reconstruction persist at the patient level, the extent to which hospital factors contribute to these differences remains unclear. The rates of immediate breast reconstruction across safety net and non-safety net hospitals were investigated. Women 21 years and older with breast cancer or increased risk of breast cancer undergoing immediate post-mastectomy reconstruction were identified in the Nationwide Inpatient Sample database. Safety net hospitals were defined as hospitals with the highest tertile of Medicaid disproportionate share hospital payment adjustments. Adjusted odds ratios of undergoing reconstruction were calculated. Thirty-one percent of patients (n = 10,910) at safety net hospitals underwent immediate reconstruction compared with 46 percent of patients (n = 14,619) at non-safety net hospitals (p < 0.001). Logistic regression revealed that women at non-safety net hospitals were significantly more likely to undergo reconstruction (OR, 1.89; 95 percent CI, 1.65 to 2.16). However, analysis by study year revealed that rates of reconstruction at safety net hospitals increased over time. After accounting for sociodemographic factors, women undergoing mastectomies at safety net hospitals remain less likely to undergo immediate breast reconstruction. However, the differences in rates of reconstruction between safety net and non-safety net hospitals have narrowed over time. The availability of immediate reconstruction lessens the psychological trauma of mastectomy, and it is critical to continue redirecting federal efforts toward this valuable component of breast cancer care. Risk, II.

The ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care.

To estimate the effect of the first full year of the ACA Medicaid expansion on hospital provision of uncompensated care, with special attention paid to hospitals that treat a disproportionate share of low-income patients. Data from a balanced panel of short-term, general, nonfederal, Medicare-certified hospitals were obtained from Medicare cost reports from 2011 to 2014. A series of difference-in-differences analyses were performed using hospitals in nonexpansion states as the control group. The dependent variable is hospital provision of uncompensated care. The data were downloaded from the National Bureau of Economic Research website. The Medicaid expansion significantly reduced hospital provision of uncompensated care in 2014. In particular, within expansion states, DSH hospitals saw reductions beyond those experienced by non-DSH hospitals. Evidence from this study indicates that the Medicaid expansion served to widen an already broad gap in provision of uncompensated care between hospitals in expansion and nonexpansion states. In addition, within expansion states, variation in uncompensated care between hospitals that treat a disproportionate share of low-income patients and those that do not was reduced, with the former experiencing significantly larger reductions. Lawmakers considering expanding Medicaid and those deciding appropriate levels of DSH payments should consider these findings.

Threshold-Based Medicare Incentives and Aggressive Patient Reporting in U.S. Hospitals

ABSTRACTThis paper examines regulatory reporting by large urban hospitals in response to financial incentives designed to increase the provision of health care services to certain underserved individuals. We find strong evidence that hospitals have used aggressive reporting to extract substantial unwarranted funding from Medicare's Disproportionate Share Hospital (DSH) program—a program designed to ease the burden on hospitals treating low income populations. Our evidence suggests that the accuracy of basic performance metrics (in this case, the number of low income patients served) can be unreliable when threshold-driven incentives based on such metrics benefit the reporting party (in this case, large urban hospitals). Similarities between the DSH program and current payment reforms, along with policy implications, are discussed.JEL Classifications: H51; I18.

Excess Deaths Among the Uninsured Before the Affordable Care Act (ACA), and Potential Post-ACA Reductions.

Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million working-age Americans remained uninsured and vulnerable to premature death because of poor health care access. The ACA-mandated phasing out of disproportionate share hospital payments that supported charity care may aggravate care access for the residual uninsured. To estimate excess deaths among the uninsured and the potential ACA impact on the basis of a recent cohort's mortality experience. We hypothesized a higher uninsured mortality risk than the available pre-2000 estimate because of worsening of care disparities owing to technology-driven advances in life-saving care. We conducted a retrospective cohort study of the 1999 to 2002 National Health and Nutrition Examination Survey respondents observed through 2011. We estimated (a) weighted Cox proportional mortality hazard of uninsured working-age adults adjusted for demographics, comorbidity, and lifestyle behaviors, (b) weighted mortality rates among the uninsured and insured within age and comorbidity strata, and (c) excess deaths because of uninsurance using the Institute of Medicine methodology. Noninstitutionalized US population. Adults aged 20 to 64 years. Mortality. Of 7274 study-eligible respondents, 20.6% were uninsured and 478 died during follow-up, for an adjusted uninsured mortality hazard ratio of 1.57 (95% confidence interval, 1.12-2.21) versus privately insured, translating to 48 529 excess deaths among the population aged 25 to 64 years in 2011 (7.8% of total deaths in this age group). The estimated proportion of excess deaths was 52% higher than the pre-2000 cohort study. The mortality disparity increased with age and comorbidity. Findings support our hypotheses, and indicate that post-ACA, a residual 4.7% excess mortality among working-age adults will continue, about 30 428 excess deaths annually. Restoration of disproportionate share hospital supports and continued advocacy for universal health care coverage are needed to reduce avoidable deaths.

Aggressive Non-Financial Reporting in Medicare Cost Reports: An Empirical Investigation of Disproportionate Patient Percentage Reporting

This paper examines the link between regulatory reporting and statutory health care reimbursement formulas. I find strong evidence that hospitals have used aggressive regulatory reporting to extract approximately $60 million per year from Medicare’s Disproportionate Share Hospital (DSH) program — a program designed to ease the burden on hospitals treating low income populations. Similarities between the DSH program and current payment reforms are discussed along with policy implications. Overall, evidence suggests that noneconomic metrics can be unreliable when threshold based incentives are present, especially when the reporting party is also the program beneficiary; and current penalties for filing inaccurate regulatory reports are ineffective at curbing reporting manipulations around thresholds.

Abstract C18: Are facility characteristics where the patient initially presented associated with breast cancer diagnostic and treatment outcomes? Implications for racial/ethnic disparities in breast cancer outcomes

Abstract Background: Non-Latina (nL) Black and Latina breast cancer patients are more likely to be diagnosed at later stages and to experience shorter survival, compared to their nL White counterparts. Many studies, both nationally and in Chicago, have documented racial/ethnic disparities in many aspects of screening, diagnosis, and treatment for breast cancer, but few have examined the role of the facility where the problem that was later diagnosed as breast cancer was initially brought to medical attention (presentation facility). Prior research, as part of the Breast Cancer Care in Chicago (BCCC) study, found that breast cancer patients who initially presented at more highly accredited facilities and at higher-resource facilities were less likely to experience a prolonged diagnostic delay, and that meaningful racial/ethnic disparities in delay could be accounted for by differences in presentation facility. While this result highlights the potential influence of presentation facility on a proximal outcome (diagnostic delay), the present analysis aimed to further examine associations with the types of diagnostic work-up and treatment delays. Methods: In the BCCC (2005-2008), 989 newly diagnosed nL White, nL Black, and Latina patients with a first primary in-situ or invasive breast cancer, aged 30-79 at diagnosis were interviewed. Of these, 848 provided consent for medical record abstraction, and so were included in these analyses. Four characteristics of presentation facilities were examined: disproportionate share hospital (DSH) status (a marker of high Medicaid and uninsured volume), certification as a Breast Imaging Center of Excellence (BICOE), membership in the National Consortium of Breast Centers (NCBC), and the National Accreditation Program for Breast Centers (NAPBC). Outcomes representing potential indicators of quality of care included receipt of surgical versus core biopsy, sentinel node vs. axillary dissection, re-excision versus not, mastectomy versus lumpectomy, and prolonged radiation (&amp;gt;90 days), chemotherapy (&amp;gt;90 days) and overall treatment delay (&amp;gt;60 days). P-values for crude analyses were based on χ2 tests of associations. Results: NL Black and Latina patients were more likely than Whites to present at a DSH facility (38% and 48% vs 12%; p&amp;lt;0.001) and less likely to present at a BICOE (45% and 49% vs. 79%, p&amp;lt;0.001) or NAPBC facility (22% and 10% vs. 53%, p&amp;lt;0.001). Presentation at a BICOE facility was inversely associated with surgical biopsy (4% vs 11%; p&amp;lt;0.001), and presentation at a NAPBC facility was positively associated with receipt of a sentinel node biopsy (68% vs 55%; p=0.003). Presentation at a DSH facility was associated with surgery delay (23% vs 13%; p=0.002) and radiation delay (69% vs 53%; p=0.005) whereas presentation at a BICOE facility was inversely associated with overall treatment delay (12% vs 20%; p=0.003) and surgery delay (14% vs 21%; p=0.01). Presentation at a NAPBC facility was inversely associated with overall treatment delay (6% vs 19%; p&amp;lt;0.001), surgery delay (9% vs 20%; p=0.001), and radiation delay (37% vs 62%; p&amp;lt;0.001) but positively associated with chemotherapy delay (81% vs 65%; p=0.003). Conclusion: Presentation facility characteristics were associated with several aspects of diagnosis and treatment quality indicators. Results implicate a role of presentation facility in diagnostic and treatment-related quality. Limitations that will be addressed in subsequent analyses include multivariable adjustment of patient and tumor factors that might influence these associations. Citation Format: Alejandro Hughes, Abigail Silva, Anne-Marie Murphy, Garth Rauscher. Are facility characteristics where the patient initially presented associated with breast cancer diagnostic and treatment outcomes? Implications for racial/ethnic disparities in breast cancer outcomes. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C18.