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Tuesday, April 26, 2016

With New Hospital Guide, CMS Recognizes Minority Communities' Barriers to Health

Neah Morton

Wellstone Fellow

We often write about how efforts to reform health care payment and delivery have the potential to fight disparities on the one hand—or unintentionally harm communities of color, on the other. Recent actions by the Center for Medicare and Medicaid Services (CMS) represent an encouraging recognition–-by one of the biggest payers of health care in the nation—that one-size-fits all payment reforms do not benefit everyone equally. And they raise the question of whether some of these pay-for-performance programs should be adjusted to better address racial and ethnic health disparities.  

New CMS guide recommends additional strategies to better serve minority Medicare patients

In an effort to improve the quality and value of Medicare services, the Affordable Care Act (ACA) created a new pay-for-performance program to reduce avoidable readmissions, the Medicare Hospital Readmissions Reduction Program (HRRP).  From its inception, concerns were raised that it could disproportionately penalize safety net hospitals that are vital providers in communities of color. These hospitals tend to serve more complex patients who struggle with multiple barriers to health and health care. And these hospitals have higher readmission rates than others. 

In a welcome move last January, CMS acknowledged the challenges these hospitals face by publishing the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries. Developed for CMS by the Disparities Solutions Center, an independent nonprofit organization, the guide, in essence, signals to hospitals that there is no level playing field when it comes to preventing readmissions among communities of color. The guide helps them look beyond their usual strategies to keep their readmissions low enough to avoid penalties.  

Safety net hospitals have been more likely to be penalized under the Hospital Readmissions Reduction Program, with one analysis finding that they were 60 percent more likely to be penalized than non-safety net hospitals, while another found that hospitals serving a high volume of low-income patients were 2.67 times more likely to be penalized in 2016.

Reducing avoidable hospital readmissions is an important quality and equity goal

The CMS readmissions program targets avoidable hospital readmissions, which have long been identified as a serious cost, quality, and patient safety issue. Generally, a readmission occurs when a patient is admitted to a hospital within 30 days of being discharged. Some readmissions can’t be helped because some complications are unavoidable and some fragile patients are bound to deteriorate. 

But there is consensus that a significant proportion of readmissions can be avoided if patients receive the proper care during, and immediately after, their initial hospitalization. Avoidable readmissions are expensive (costing an estimated $17 billion a year), hard on patients and their families, and bad for your health. 

The CMS program tries to promote better care quality and value by cutting payments to hospitals with “excessive” readmissions for certain conditions.  Because it’s impossible for CMS to review every readmission to determine which were avoidable, it created a formula (adjusted by some factors like age and severity of illness) to establish a threshold beyond which additional readmissions are considered “excessive.” Currently, it applies to heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and elective hip or knee replacement. Hospitals with excessive readmissions lose a certain percentage (up to 3 percent) of their total Medicare payments.  This makes the program a relatively blunt instrument to address a complex problem.

Certain racial and ethnic groups experience higher readmission rates

Readmission rates for a variety of different conditions are higher among certain racial and ethnic groups. For example, one 2011 study of Medicare heart attack, heart failure, and pneumonia patients found African Americans had a readmissions rate about 10 percent higher than non-Hispanic Whites. A similar study of surgery patients found a 16 percent higher rate for African Americans. Outcomes for Hispanic heart attack patients also showed a 10 percent higher readmissions rate, compared to whites.  

Penalizing hospitals for readmissions could have negative unintended consequences for communities of color and other vulnerable people

The readmissions reduction program appears to be helping to reduce preventable readmissions. However, some experts, community advocates, and safety net hospitals voiced concerns to CMS about the program’s potential unintended effect on hospitals that serve a higher share of medically and socially complex patients who are more likely to be readmitted for reasons outside the hospital’s control.

The CMS program didn’t factor in the multiple barriers to health and health care that can drive readmissions in communities of color.

It was already known that hospitals serving predominantly minority patients had 16 percent higher readmission rates than others. Yet, the CMS program didn’t factor in the multiple barriers to health and health care that can drive readmissions in communities of color. These include social and economic barriers such as:

  • Concentrated poverty
  • Transportation challenges
  • Unhealthy environments
  • Lower educational and literacy levels
  • Limited English proficiency
  • Limited social support

Yet these safety net and minority-serving hospitals are the lifeline for many minority and other vulnerable communities. Reducing their Medicare payments could potentially undermine their ability to continue providing care.  It also could create a strong perverse incentive for hospitals to avoid treating these patients. The data backs up this concern. 

Safety net hospitals have been more likely to be penalized under the HRRP, with one analysis finding that they were 60 percent more likely to be penalized all three years than non-safety net hospitals, while another found that hospitals serving a high volume of low-income patients were 2.67 times more likely to be penalized in 2016. 

This demonstrates why, given this country’s demographic shift to a majority minority nation, payment reforms that ignore the deep variations in health risk and opportunity that exist between communities will not only fall short, they could inadvertently imperil the health of communities of color.   

New CMS guide recognizes that reducing health disparities requires tailored approaches

The good news is that payers and providers are starting to realize that improving health outcomes, including lowering the rate of avoidable readmissions, requires addressing the many factors, outside of their walls, that keep their patients from getting, and staying healthy. The CMS guide is an important recognition of this, by one of the most influential payers of health care in the country. 

The guide lays out seven strategies hospitals should adopt to reduce readmissions in communities of color, including strong data collection, leveraging that data (“creating a strong radar”), determining “root causes” of readmissions, considering social determinants, and working with community partners to enhance continuity of care.  

More needs to be done to ensure that payment reform advances health equity, and diverse voices are needed in this effort

CMS’s acknowledgement that communities of color often need tailored approaches and additional resources to get and stay healthy is just a first step. Advocates, experts, and policy makers have recommended that the HRPP formula itself be adjusted for sociodemographic factors. CMS is now working with the National Quality Forum (NQF), an independent entity that develops and tracks quality measures, to pilot this in the future.  

But this is the tip of the iceberg. It is essential that advocates from communities of color actively work with policy makers and providers to make sure that health system transformation accelerate health equity.