American College of Cardiology

American College of Cardiology

March 17, 2019
2 min read

Safety-net hospitals bear brunt of financial penalties for HF readmissions

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Sameed Ahmed M. Khatana
Sameed Ahmed M. Khatana

NEW ORLEANS — Safety-net hospitals, defined as those in socioeconomically disadvantaged areas, are more likely than other hospitals to be penalized by CMS for high 30-day HF readmission rates, according to a presentation at the American College of Cardiology Scientific Session.

However, CMS has amended its penalty formula starting in fiscal year 2019, which will reduce the proportion of penalties paid by safety-net hospitals, but raises questions about whether patients with HF at safety-net hospitals will be treated equitably, Sameed Ahmed M. Khatana, MD, cardiology fellow at the University of Pennsylvania, said during a presentation.

Previous research has demonstrated that all-cause HF death or readmission at 6 months is 50% higher in patients from neighborhoods with low socioeconomic status compared with those from neighborhoods with high socioeconomic status, Khatana said here.

The Hospital Readmission Reduction Program, begun by CMS in 2012, reduces Medicare inpatient payments to hospitals based on a formula of the ratio of predicted to expected readmissions; institutions are compared with those with a similar case-mix index, he said.

However, under this formula, safety-net hospitals, which already provide a disproportionate share of uncompensated care, were more likely to be penalized, according to Khatana, who noted that safety-net hospitals had an average penalty of 0.7% compared with 0.51% for hospitals in high-income neighborhoods in fiscal year 2017.

“A challenge is that no single approach has consistently reduced readmission rates, although a multipronged approach appears to be helpful,” he said. “Safety-net hospitals report more barriers to implementing strategies and lower utilization of strategies.”

Patient-related barriers include mental health and substance abuse disorders, homelessness and lack of transportation. Community-related barriers include poor mental health and substance abuse services and lack of primary care. Hospital-related barriers include lack of primary care and insufficient staffing, Khatana said.

Under the 21st Century Cures Act, CMS starting in fiscal year 2019 must account for socioeconomic status in the Hospital Readmission Reduction Program, which will lead to fewer penalties for safety-net hospitals but more penalties for other hospitals “because of a mandate to be revenue-neutral,” he said.

However, he said, in the Hospital Value-based Purchasing Program, which includes 30-day HF mortality as a metric, safety-net hospitals do not have greater 30-day HF mortality than other hospitals, but have been disproportionately penalized because of lower nonclinical scores, especially in patient experience.

“The issue is complicated because there are tradeoffs between lower quality of care to patients with lower socioeconomic status and penalties for safety-net hospitals,” Khatana said. “Possible solutions include measuring and identifying the causes of disparities, identifying the measures that are more reasonable to adjust for socioeconomic status, accounting for the financial health of safety-net hospitals, identifying the causes for heterogeneity among safety-net hospitals and having payment models incentivize care for vulnerable populations.” – by Erik Swain


Khatana SAM. The right quality and performance metrics and the right outcomes in heart failure. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.

Disclosure : Khatana reports no relevant financial disclosures.