Disproportionate Share Hospital Research Articles

Association Between Medicare Star Ratings for Patient Experience and Medicare Spending per Beneficiary for US Hospitals.

Objective:To test the association between patient experience and Centers for Medicare and Medicaid Services (CMS) spending at the hospital level.Methods:Using CMS Hospital Compare data set, we analyzed 2014 data for CMS patient experience star ratings and the hospital Medicare Spending per Beneficiary (MSPB) Measure, which assesses price-standardized, risk-adjusted payments for services provided to Medicare beneficiaries for an episode of care from 3 days before hospital admission to 30 days following discharge. We tested the association using linear regression, adjusting for complexity of care using hospital Case Mix Index (CMI) and for socioeconomic status of the hospital patient population using Disproportionate Share Hospital (DSH) status.Results:The MSPB decreased with increasing hospital patient experience ratings. After adjustment for CMI and DSH, better hospital patient experience was associated with lower spending per episode (5.6% decrease from the lowest to highest patient experience star rating).Conclusion:We found that better hospital patient experience was associated with lower health-care spending. Further research is needed to define what specific elements and phases of the episode of care are driving the association.

Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010-Fiscal Year 2011.

To compare Medicaid fee-for-service (FFS) inpatient hospital payments to expected Medicare payments. Medicaid and Medicare claims data, Medicare's MS-DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Medicaid FFS inpatient hospital claims were run through Medicare's MS-DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included.

For Disproportionate-Share Hospitals, Taxes And Fees Curtail Medicaid Payments.

After accounting for supplemental payments, we found that in 2011, disproportionate-share hospitals, on average, received gross Medicaid payments that totaled 108percent of their costs for treating Medicaid patients but only 89percent of their costs for Medicaid and uninsured patients combined. However, these payments were reduced by approximately 4-11percent after we accounted for provider taxes and local government contributions that are used to help finance Medicaid payments.

Contrary To Popular Belief, Medicaid Hospital Admissions Are Often Profitable Because Of Additional Medicare Payments.

It is generally believed that most hospitals lose money on Medicaid admissions. The data suggest otherwise. Medicaid admissions are often profitable for hospitals because of payments from both the Medicaid program and the Medicare program, including payments for uncompensated care and from the Medicare disproportionate-share hospital program. On average, adding a single Medicaid patient day in fiscal year 2017 will increase most hospitals' Medicare payments by more than $300. When added to Medicaid payments, these payments often cause Medicaid patients to be profitable for hospitals. In contrast, adding a single charity care day in the same year will decrease overall Medicare payments by about $20 on average. The Centers for Medicare and Medicaid Services recently announced a proposal to shift some Medicare payments from supporting hospitals' costs for Medicaid patients to directly supporting their costs for uncompensated care. If that proposal is adopted, hospitals' profits on Medicaid patients would decrease, but their losses on care for the uninsured would be reduced.

Financial Loss for Inpatient Care of Medicaid-Insured Children

Medicaid payments tend to be less than the cost of care. Federal Disproportionate Share Hospital (DSH) payments help hospitals recover such uncompensated costs of Medicaid-insured and uninsured patients. The Patient Protection and Affordable Care Act reduces DSH payments in anticipation of fewer uninsured patients and therefore decreased uncompensated care. However, unlike adults, few hospitalized children are uninsured, while many have Medicaid coverage. Therefore, DSH payment reductions may expose extensive Medicaid financial losses for hospitals serving large absolute numbers of children. To identify types of hospitals with the highest Medicaid losses from pediatric inpatient care and to estimate the proportion of losses recovered through DSH payments. This retrospective cross-sectional analysis evaluated Medicaid-insured hospital discharges of patients 20 years and younger from 23 states in the 2009 Kids' Inpatient Database. The dates of the analysis were March to September 2015. Hospitals were categorized as freestanding children's hospitals (FSCHs), children's hospitals within general hospitals, non-children's hospital teaching hospitals, and non-children's hospital nonteaching hospitals. Financial records of FSCHs in the data set were used to estimate the proportion of Medicaid losses recovered through DSH payments. Hospital financial losses from inpatient care of Medicaid-insured children (defined as the reimbursement minus the cost of care) were compared across hospital types. For our subsample of FSCHs, Medicaid-insured inpatient financial losses were calculated with and without each hospital's DSH payment. The 2009 Kids' Inpatient Database study population included 1485 hospitals and 843 725 Medicaid-insured discharges. Freestanding children's hospitals had a higher median number of Medicaid-insured discharges (4082; interquartile range [IQR], 3524-5213) vs non-children's hospital teaching hospitals (674; IQR, 258-1414) and non-children's hospital nonteaching hospitals (161; IQR, 41-420). Freestanding children's hospitals had the largest median Medicaid losses from pediatric inpatient care (-$9 722 367; IQR, -$16 248 369 to -$2 137 902). Smaller losses were experienced by non-children's hospital teaching hospitals (-$204 100; IQR, -$1 014 100 to $14 700]) and non-children's hospital nonteaching hospitals (-$28 310; IQR, -$152 370 to $9040]). Disproportionate Share Hospital payments to FSCHs reduced their Medicaid losses by almost half. Estimated financial losses from pediatric inpatients covered by Medicaid were much larger for FSCHs than for other hospital types. For children's hospitals, small anticipated increases in insured children are unlikely to offset the reductions in DSH payments.

Association of minority-serving hospitals with lower resources for cancer care.

6547 Background: Disparities in colorectal cancer (CRC) are longstanding. Previous studies show links between minority use of low quality hospitals, suggesting a role for location of care in disparities. No studies have linked the impact of hospital structure with processes of care in minority serving hospitals (MSH). The purpose of this study is to compare structural factors; financial characteristics and processes of care in MSH versus other settings. Hypothesis: MSH have fewer structural and financial resources for cancer care and lower adherence to evidence-based care. Methods: California Cancer Registry linked with patient discharge data and hospital characteristics identified all cases of CRC in California (2001-2006). MSH was defined by top quartile of minority discharges in the state. Structural characteristics included teaching hospital, CRC volume, rural location, NCI and Commission on Cancer (CoC) accreditation. Financial characteristics included disproportionate share; Medicaid utilization and ownership. Evidence based care was defined by the National Comprehensive Cancer Network (NCCN). Chi-square analysis tested for significant differences between hospital groups. Results: Of 354 hospitals, 96 (27%) were MSH. Compared to non-MSH, there was no difference in the proportion of academic MSH. A quarter of MSH were high volume versus non-MSH settings (39%, p = 0.04). Only 3% of MSH were rural versus non-MSH (16.3%, p < 0.001). There were no NCI accredited MSH (versus 9 non-MSH, p = 0.03); and only 20% were CoC accredited (versus 33.3% non-MSH; p = 0.03). The majority of MSH (68%) were disproportionate share hospitals (versus 16% of non-MSH; p = 0.001). More MSH were high Medicaid service settings (52% vs. 2.4%; p < 0.0001). There was no difference in hospital ownership. More MSH settings had low level compliance with delivery of appropriate surgery (50% versus 25.6%; p < 0.0001); delivery of indicated radiation (38.7% versus 31.2; p < 0.001). There was no difference in chemotherapy. Conclusions: Minority serving hospitals in California have limited infrastructure to deliver high quality cancer care which may explain low guideline adherence. MSH use may explain disparities in CRC and may provide targets for interventions to address them.

Creating the Business Case for Achieving Health Equity.

Health care organizations have increasingly acknowledged the presence of health care disparities across race/ethnicity and socioeconomic status, but significantly fewer have made health equity for diverse patients a true priority. Lack of financial incentives is a major barrier to achieving health equity. To create a business case for equity, governmental and private payors can: 1) Require health care organizations to report clinical performance data stratified by race, ethnicity, and socioeconomic status. 2) Incentivize preventive care and primary care. Implement more aggressive shared savings plans, update physician relative value unit fee schedules, and encourage partnerships across clinical and non-clinical sectors. 3) Incentivize the reduction of health disparities with equity accountability measures in payment programs. 4) Align equity accountability measures across public and private payors. 5) Assist safety-net organizations. Provide adequate Medicaid reimbursement, risk-adjust clinical performance scores for sociodemographic characteristics of patients, provide support for quality improvement efforts, and calibrate cuts to Disproportionate Share Hospital (DSH) payments to the pace of health insurance expansion. 6) Conduct demonstration projects to test payment and delivery system reform interventions to reduce disparities. Commitment to social justice is essential to achieve health equity, but insufficient without a strong business case that makes interventions financially feasible.

Breast cancer: Does where you get treated affect survival?

28 Background: Under the ACA, more women are insured with Medicaid which should improve access to cancer care. However, Disproportionate Share Hospitals (DSH) are due to receive reduced subsidies thereby threatening resource stressed facilities and poorer hospitals are experiencing greater financial penalties due to higher readmission rates. In NYS, 83% of Medicaid breast cancer patients got their cancer surgery at DSH hospitals. As women gain more choice and access, they will require information about hospitals’ quality and outcomes of cancer care. We sought to determine whether there are survival advantages among breast cancer patients treated at hospitals with varying proportions of Medicaid patients. Methods: We used non-obstetric delivery Medicaid discharges from NYS hospitals in 2005-13 to create quintiles of hospitalized patients with Medicaid. Women treated for breast cancer were identified with a diagnostic and procedure code for breast cancer. Based on NYS hospital discharge database linked with vital statistics death records, we calculated hazard ratios using marginal Cox model with a robust sandwich variance estimator controlling for clustering of patients within the hospital, age and comorbidity. Results: Quintiles of Medicaid hospitals ranged from low (0-15%), to low medium (15-22%), medium (22-29%), medium-high (29-50%), to high ( &gt; 50%). 26% of breast cancer patients were treated at the low; 22% at the low medium; 20% at the medium; 21% at the medium-high and 11% at high quintile hospitals. Patients treated in hospitals with &gt; 50% Medicaid patients had a higher long-term mortality (HR = 1.51; 95%CI: 1.19-1.93) compared to those treated at the lowest quintile hospitals. Sensitivity analyses to adjust for stage are underway. Conclusions: While the ACA may improve access to breast cancer treatment, the long term impact on survival remains questionable as women with breast cancer treated at hospitals with high proportions of Medicaid patients may have worse survival. Analyses to control for stage are underway. Pending these results, hospitals with high proportions of Medicaid patients may need to target cancer quality improvement efforts to assure equitable outcomes.

Understanding Value-Based Incentive Models and Using Performance as a Strategic Advantage

The Centers for Medicare & Medicaid Services (CMS) implemented hospital quality incentive and penalty programs as part of the Affordable Care Act, and they are the starting points for transitioning to value-based payment. Not only do the programs affect hospitals' bottom line, but they also could affect their market position because of the transparency of results. Thus, creating an effective strategy to succeed under these programs is important.The authors address some important questions about the CMS incentive and penalty programs.What upside benefits and downside penalties do the CMS incentive and penalty models offer hospitals?The CMS quality- and value-based incentive and penalty models will collectively put up to 6% of hospitals' Medicare payments at risk by 2017 (Rau, 2015). The three CMS programs are the Value-Based Purchasing (VBP) program, the Hospital Readmissions Reduction Program (HRRP), and the Hospital-Acquired Conditions (HAC) program. As part of healthcare reform, these programs are designed to transition hospitals to more value-based reimbursement by incentivizing or penalizing providers on the basis of their performance on certain quality metrics. These three programs reflect a fundamental change in how Medicare reimburses hospitals for services and in how hospitals manage and monitor quality performance. The VBP program is the only one of the three that has upside benefits in providing a bonus; the HRRP and HAC programs are strictly penalty programs for hospitals that do not perform well under the criteria established by CMS.The VBP program is technically a payment redistribution program in that eligible hospitals contribute a set percentage of base operating payments to a VBP payment pool; the percentage is 1.75% for fiscal year (FY) 2016 and 2% for FY 2017. This VBP payment pool is used to provide a to hospitals for performance on the VBP criteria, which are grouped into the domains of process of care, outcomes, patient experience, and efficiency. Thus, all hospitals pay into the pool, and if they do not perform well, their bonus could be less than the amount of their contribution (i.e., a net penalty). On the other hand, hospitals that perform well receive a payment that is more than the amount they paid in (i.e., a net bonus).HRRP and HAC programs are strictly penalty programs. HRRP issues a penalty of up to 3% for hospitals with excessive avoidable readmissions, and HAC issues a 1% penalty for hospitals whose performance is in the bottom quartile. However, the 1% penalty under HAC is not limited to the hospital base operating payment, but is also applied to add-on payments, such as those for outliers, disproportionate share hospitals, uncompensated care, and indirect medical education, making its impact more pronounced. On the basis of CMS data (2015a), we estimated the average penalty for FY 2015 to be $520,000 per penalized hospital under the HAC program, whereas the average readmissions penalty was projected to be $165,000.Is the magnitude of the benefits and penalties substantial enough to warrant being proactive?For FY 2016, only 799 of 3,414 eligible hospitals (23%) avoided a penalty for excessive avoidable readmissions, meaning that 77% of eligible hospitals are being penalized under HRRP (CMS, 2015b). (Readmissions data are based on a rolling 3-year assessment period; for FY 2016, the data are from July 1, 2011, to June 30, 2014.) However, the penalty for the majority of hospitals was in the range of 0.01% to 0.5%, and both the number of hospitals penalized and the average penalty fell from the levels in FY 2015. Since enactment of the readmissions penalties in 2013, readmissions have dropped, but approximately one in five patients admitted to the hospital is still readmitted within 30 days of discharge. In FY 2017, a new condition-coronary artery bypass graft-will be added to the list of measured conditions for HRRP. Historically, CMS has added a new condition every other year, and hospitals typically struggle when new conditions are added. …

Racial/Ethnic Disparities in Time to a Breast Cancer Diagnosis: The Mediating Effects of Health Care Facility Factors.

Racial/ethnic disparities exist along the breast cancer continuum, including time to a diagnosis. Previous research has largely focused on patient-level factors, and less is known about the role that health care facilities may play in delayed breast cancer care. We examined racial/ethnic disparities in delayed diagnosis for breast cancer in the Breast Cancer Care in Chicago Study and estimated the potential mediating effects of facility factors. Breast cancer patients (N=606) contributed interview and medical record data as part of a population-based study. Race/ethnicity was self-reported at interview. Diagnostic delay was defined as an excess of 60 days between medical presentation and a definitive diagnosis. Facility factors included the facility of medical presentation with respect to: (1) accreditation through the National Consortium of Breast Centers; (2) certification as a Breast Imaging Center of Excellence through the American College of Radiology; and (3) status as a disproportionate share hospital through the state of Illinois as well as the number of facilities used between presentation and diagnosis. Relative to non-Hispanic whites, minorities were more likely to experience a diagnostic delay, present at a nonaccredited facility and at a disproportionate share hospital, and involve multiple facilities in their diagnosis. Together, facility factors accounted for 43% of the disparity in diagnostic delay (P<0.0001). Initial presentation of breast cancer at higher resourced facilities can reduce diagnostic delays. Disparities in delay are partly due to a disproportionate presentation at lower resourced facilities by minorities.

The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study.

Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals. To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP. Cross-sectional analysis. United States in 2014. 3022 acute care hospitals participating in VBP and the HRRP. Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods. Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115900 vs. $66600 and $150100 vs. $54900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures. Only 2 measures of safety-net status were included in the analyses. Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014. Patient-Centered Outcomes Research Institute.

Linking Medicaid Expansion and Cuts to Disproportionate-Share Hospitals: Will Safety Nets Survive?

The predominant mechanism by which the health care reforms of the Patient Protection and Affordable Care Act of 2010 are to be financed is through the government's simultaneous defunding of major portions of Medicare and Medicaid, including the reduction of up to 75% of federal payments to disproportionate-share hospitals. The justification for curtailment of other public programs is that after Medicaid expansion under the Affordable Care Act, the decrease in the proportion of uninsured among the U.S. population will render disproportionate-share hospital payments extraneous and unnecessary. Such justification was reiterated in the recent American College of Obstetricians and Gynecologists Committee Opinion No. 627, entitled Health Care for Unauthorized Immigrants. Herein, the soundness of the Committee Opinion's proposed policy is evaluated by reviewing available literature on the potential effect of Medicaid disproportionate-share hospital cuts with and without concomitant Medicaid expansion. Limitations of Medicaid expansion efforts before and under the Affordable Care Act, the disproportionate-share hospital payment program, and other legislation providing safety net hospitals with (some) relief of financial burdens related to uncompensated care are explicated. Findings raise concern that acceptance of cuts of up to 75% of federal disproportionate-share hospital funds on the premise that nationwide state expansion of Medicaid will offset the difference may be overly optimistic. Indeed, foregoing disproportionate-share hospital payments undercuts the otherwise laudable intent of Committee Opinion No. 627, namely to advocate for universal health care for all women, including undocumented immigrants.

New York state hospitals serving the poor: Does the proportion of Medicaid patients affect lung cancer surgical short-term outcomes?

e17660 Background: Historically, hospitals serving the poor provide worse quality care. Under the Affordable Care Act, Disproportionate Share Hospitals (DSH) will receive reduced reimbursement whic...

Predictors of Payer Mix and Financial Performance Among Safety Net Hospitals Prior to the Affordable Care Act.

The objective of this study was to use audited hospital financial statements to identify predictors of payer mix and financial performance in safety net hospitals prior to the Affordable Care Act. We analyzed the 2010 financial statements of 98 large, urban safety net hospital systems in 34 states, supplemented with data on population demographics, hospital features, and state policies. We used multivariate regression to identify independent predictors of three outcomes: 1) Medicaid-reliant payer mix (hospitals for which at least 25% of hospital days are paid for by Medicaid); 2) safety net revenue-to-cost ratio (Medicaid and Medicare Disproportionate Share Hospital payments and local government transfers, divided by charity care costs and Medicaid payment shortfall); and 3) operating margin. Medicaid-reliant payer mix was positively associated with more inclusive state Medicaid eligibility criteria and more minority patients. More inclusive Medicaid eligibility and higher Medicaid reimbursement rates positively predicted safety net revenue-to-cost ratio. University governance was the strongest positive predictor of operating margin. Safety net hospital financial performance varied considerably. Academic hospitals had higher operating margins, while more generous Medicaid eligibility and reimbursement policies improved hospitals' ability to recoup costs. Institutional and state policies may outweigh patient demographics in the financial health of safety net hospitals.

Indications of biased risk adjustment in the hospital readmission reduction program.

The Centers for Medicare and Medicaid Services hospital readmission reduction program administers substantial penalties to hospitals with excess readmissions. In our analysis of Medicare claims data, we find hospitals with the highest percentages of patients with several chronic conditions and advanced age have excess readmission ratios that are overstated because of inadequate risk adjustment. The distribution of chronic conditions and age is sufficient to cause 4.5% (heart failure), 6.2% (pneumonia), and 13.8% (acute myocardial infarction) of high disproportionate share hospitals to inappropriately receive penalties out of keeping with the intent of the hospital readmission reduction program. We believe that the risk adjustment model underlying the HRRP requires urgent independent review.

The 340B Discount Program: Outpatient Prescription Dispensing Patterns Through Contract Pharmacies In 2012

Section340B of the Public Health Service Act provides qualified organizations serving vulnerable populations with deep discounts for some outpatient medications. A 2010 regulatory change widely expanded the 340B program's reach, allowing these organizations to contract with retail pharmacies to dispense medications for eligible patients. Little is known about which medications are dispensed by contract pharmacies under the expanded program. We provide the first comparison of 340B prescriptions and all prescriptions dispensed in contract pharmacies. We used 2012 data from Walgreens, the national leader in 340B contract pharmacies. Medications used to treat chronic conditions such as diabetes, high cholesterol levels, asthma, and depression accounted for an overwhelming majority of all prescriptions dispensed at Walgreens as part of the 340B program. A higher percentage of antiretrovirals used to treat HIV/AIDS were dispensed through 340B prescriptions than through all prescriptions dispensed at Walgreens. The majority of 340B prescriptions dispensed at Walgreens originated at tuberculosis clinics, consolidated health centers, disproportionate-share hospitals, and Ryan White clinics. Our results suggest that 340B contract pharmacies dispense medications used to treat Americans' chronic disease burden and disproportionately dispense medications used by key vulnerable populations targeted by the program.

Identifying hospitals that may be at most financial risk from Medicaid disproportionate-share hospital payment cuts.

Medicaid disproportionate-share hospital (DSH) payments are expected to decline by $35.1billion between fiscal years2017 and 2024, a reduction brought about by the Affordable Care Act (ACA) and recent congressional action. DSH payments have long been a feature of the Medicaid program, intended to partially offset uncompensated care costs incurred by hospitals that treat uninsured and Medicaid populations. The DSH payment cuts were predicated on the expectation that the ACA's expansion of health insurance to millions of Americans would bring about a decline in many hospitals' uncompensated care costs. However, the decision of twenty-five states not to expand their Medicaid programs, combined with residual coverage gaps, may leave as many as thirty million people uninsured, and hospitals will bear the burden of their uncompensated care costs. We sought to identify the hospitals that may be the most financially vulnerable to reductions in Medicaid DSH payments. We found that of the 529 acute care hospitals that will be particularly affected by the cuts, 225 (42.5percent) are in weak financial condition. Policy makers should recognize that decreases in revenue may affect these hospitals' ability to give vulnerable populations access to care.

The Affordable Care Act and orthopaedic trauma.

The Affordable Care Act has resulted in a dramatic governmental restructuring of the healthcare insurance market and delivery system. Orthopaedic traumatologists must be aware of the law's impact on their clinical practice, finances, and overall business model. This includes the effect of accountable care organizations, the Independent Payment Advisory Board, and the Physician Value-Based Payment Modifier program, as well as the impact of the Affordable Care Act's grace period provision, medical device excise tax, and cuts to funding for the Disproportionate Share Hospital program.

The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy.

Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction.We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005–2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics.Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status.Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman’s race/ethnicity, the place of service influences the likelihood of reconstruction.

California safety-net hospitals likely to be penalized by ACA value, readmission, and meaningful-use programs.

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.