Charleen Hsuan

​Summary: To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients ("peer group hospitals"). Whether the change fully accounts for patients' social and functional risks is unknown

Authors examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors.

Using 2000–2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, authors identified latent factors for patient social and functional factors and community factors. Authors estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: "base" (HRRP model); "patient" (base plus patient factors); "community" (base plus community factors); and "full" (all factors). The proportion of hospitals penalized was calculated by safety net status. Authors looked at 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations.

Findings: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized.

Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patient-level risk.

Read the Publication:

• Journal Article: Are Improvements Still Needed to the Modified Hospital Readmissions Reduction Program: a Health and Retirement Study (2000–2014)? 

​This study aimed to examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs. private. Authors analyzed ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007).

• Charleen Hsuan, JD, PhD
• Ninez A. Ponce, PhD, MPP
• Thomas Rice, PhD
• Jack Needleman, PhD, FAAN
• et al

Medicare’s Hospital Readmissions Reduction Program (HRRP) was intended to encourage hospitals to improve care for older adults. However, the program has raised health equity concerns because its risk-adjustment model does not account for patient social complexity; the concern is that HRRP may aggravate health care disparities by penalizing financially challenged hospitals and reducing their resources to improve care. Authors examined 1,742 observations for fee-for-service Medicare beneficiaries ages ≥ 65 years from 2006 to 2012 Medicare hospital and linked Health and Retirement Study (HRS) data. Social support data were obtained from the HRS Psychosocial and Lifestyle Questionnaire (PLQ), given every other wave to a randomly chosen half of the full HRS sample. Outcomes were CMS unplanned hospital-wide 30-day readmissions.

Authors compared the discrimination of three models: (1) the CMS base model (adjusting for age, sex, and clinical risk factors), (2) the CMS base model additionally adjusting for patient sociodemographics, functional/health status, health behaviors, and social factors (“full model”), and (3) the CMS base model additionally adjusting for income and race (“proxy model”). Patient health and social factors and healthy behavior were modeled as four latent factors using factor analysis: (1) socioeconomic status was indicated by household income and wealth; (2) poor health and functioning by self-rated health, indices of chronic conditions and difficulties with activities of daily living (ADL) and instrumental ADLs, receipt of home care, cognitive impairment, and use of psychiatric medications; (3) negative social support was indicated by negative support from spouse, child, other family, and friends; and (4) healthy behaviors by regular vigorous, moderate, and light household physical activity. Predictiveness was measured using model concordance, or the c-statistic.

The sample had an average age of 74.8 years and was majority male. On average, respondents had two chronic conditions, with 35% reporting fair or poor health. Overall, 11.9% of respondents were readmitted. We observed limited differences in latent factors measuring health/functioning, social factors, and health behaviors by readmission status. In multivariable analyses, compared to the base CMS model, the full model had better predictiveness, but the proxy model did not.

• Geoffrey J. Hoffman
• Charleen Hsuan, JD, PhD
• Ninez A. Ponce, PhD, MPP
• et al

​The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare-participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. 

The study examines the reasons for noncompliance and proposes solutions. Authors conducted 11 semi-structured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. 

Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high-referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians.

• Charleen Hsuan, JD, PhD
• Ninez A. Ponce, PhD, MPP
• Jack Needleman, PhD, FAAN
• et al