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Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings
Andrew S Oseran1, Rishi K Wadhera2, E John Orav3
1Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.).
Background:
Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.
Objective:
To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures.
Design:
Cross-sectional.
Setting:
Population-based.
Participants:
Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program.
Measurements:
Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated.
Results:
Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings.
Limitation:
Hospital performance measurement and risk adjustment differed slightly from those used by Medicare.
Conclusion:
Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance.
Primary Funding Source:
Laura and John Arnold Foundation.
Insights
Including Medicare Advantage (MA) beneficiaries in hospital performance evaluations significantly reclassifies rankings. Approximately 1 in 4 top-performing hospitals fall to lower tiers, indicating current Medicare value-based programs offer an incomplete performance picture.
Area of Science:
- Health Services Research
- Public Health Policy
- Healthcare Quality Improvement
Background:
- Medicare payment models link hospital performance to outcomes for fee-for-service (FFS) beneficiaries.
- The impact of including Medicare Advantage (MA) beneficiaries on these hospital performance rankings is not well understood.
Purpose of the Study:
- To assess whether including MA beneficiaries in readmission and mortality measures alters hospital performance rankings compared to current FFS-only measures.
Main Methods:
- A cross-sectional, population-based study analyzed 100% Medicare claims data (FFS and MA).
- Calculated 30-day risk-adjusted readmissions and mortality for key conditions (AMI, HF, COPD, pneumonia).
- Compared hospital performance quintiles based on FFS-only beneficiaries versus FFS and MA beneficiaries.
Main Results:
- 21.6% to 30.2% of top-performing hospitals were reclassified to lower quintiles when MA beneficiaries were included.
- Hospitals with a higher proportion of MA beneficiaries tended to show improved performance rankings.
- Similar reclassification proportions were observed from bottom to higher performance quintiles.
Conclusions:
- Including MA beneficiaries in performance evaluations reclassifies approximately 1 in 4 top-performing hospitals to lower tiers.
- Current Medicare value-based programs may provide an incomplete assessment of hospital performance.
- Hospital performance measurement needs to incorporate MA beneficiaries for a comprehensive evaluation.
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