Joynt Maddox, Karen E

Ryan, Andrew M

Shashikumar, Sukruth A

English

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Washington University School of Medicine Digital Commons@Becker 2020-Current year OA Pubs Open Access Publications 12-2-2022 Equity implications of hospital penalties during 4 years of the Comprehensive Care for Joint Replacement model, 2016 to 2019 Sukruth A Shashikumar Washington University School of Medicine in St Louis Andrew M Ryan Brown University Karen E Joynt Maddox Washington University School of Medicine in St Louis Follow this and additional works at: https://digitalcommons.wustl.edu/oa_4  Part of the Medicine and Health Sciences Commons Please let us know how this document benefits you. Recommended Citation Shashikumar, Sukruth A; Ryan, Andrew M; and Joynt Maddox, Karen E, "Equity implications of hospital penalties during 4 years of the Comprehensive Care for Joint Replacement model, 2016 to 2019." JAMA Health Forum. 3, 12. e224455 (2022). https://digitalcommons.wustl.edu/oa_4/1128 This Open Access Publication is brought to you for free and open access by the Open Access Publications at Digital Commons@Becker. It has been accepted for inclusion in 2020-Current year OA Pubs by an authorized administrator of Digital Commons@Becker. For more information, please contact vanam@wustl.edu. Research LetterEquity Implications of Hospital Penalties During 4 Years of theComprehensive Care for Joint Replacement Model, 2016 to 2019Sukruth A. Shashikumar, AB; Andrew M. Ryan, PhD; Karen E. Joynt Maddox, MD, MPHIntroductionComprehensive Care for Joint Replacement (CJR) is a mandatory Medicare bundled payment modelin which hospitals receive a target spending price for joint replacement episodes spanning fromadmission through 90 days after discharge. Hospitals that reduce spending below their targetreceive a bonus; those that fail to do so are financially penalized.From 2016 to 2019, CJR incrementally shifted target prices from hospital-specific targets toregional targets.1 Although participation was initially mandatory for hospitals in 67 randomly selectedmarkets, only hospitals in the 34 highest cost markets were mandated to participate after 2017.1 Littleis known about how Medicare distributed penalties under these policy changes. Given thedisproportionate penalization of safety-net hospitals and hospitals serving Black and Hispanicpatients under value-based payment,2,3 understanding trends in their penalization status under CJRhas important equity implications as Medicare expands bundled payment.MethodsWe obtained CJR performance information from Medicare data1 and hospital characteristics from2016 to 2019 Impact Files, 2017 inpatient claims, and the 2018 American Hospital Association Survey.Hospitals without data were excluded (15 in 2016, 16 in 2017, 6 in 2018, and 1 in 2019). Hospitals withhigh Black and Hispanic populations were defined as those in the top quintile of proportion ofpatients of Black and Hispanic race and ethnicity. Safety-net hospitals were defined as those in thetop quintile of Disproportionate Share Hospital index.Calculating marginal effect sizes from multivariate regressions in Stata/BE version 17.0 betweenJune 6, 2022, and September 23, 2022, we tested associations between caseloads with Black andHispanic populations and Disproportionate Share Hospital index and the receipt of penalties,controlling for hospital characteristics and case mix. Two-tailed P < .05 was considered statisticallysignificant. The Washington University Human Research Protection Office approved this cross-sectional study, which followed the STROBE reporting guideline. Informed consent was waived dueto the deidentified nature of the data.ResultsWe identified 735 unique hospitals in CJR between 2016 and 2019, contributing 2161 hospital-yearsof participation. The highest annual participation was in 2017, with 702 hospitals, while the lowestannual participation was in 2018, with 389 hospitals (Table). The percentage of mandatoryparticipant hospitals penalized increased yearly (Figure). In 2017, 23.1% (162) of mandatoryparticipants were penalized, including 39.3% (5) of safety-net hospitals and 41.4% (58) of hospitalswith high Black and Hispanic populations. After low-cost hospitals were allowed to exit in 2018,44.5% (173) of hospitals whose participation remained mandatory were penalized, including 69.7%(62) of safety-net hospitals and 64.4% (58) of hospitals with high Black and Hispanic populations. In+ EditorialAuthor affiliations and article information arelisted at the end of this article.Open Access. This is an open access article distributed under the terms of the CC-BY License.JAMA Health Forum. 2022;3(12):e224455. doi:10.1001/jamahealthforum.2022.4455 (Reprinted) December 2, 2022 1/4Downloaded From: https://jamanetwork.com/ by a Washington University - St Louis User  on 02/05/20232019, 52.8% (209) of mandatory participants were penalized, including 87.9% (80) of safety-nethospitals and 71.7% (66) of hospitals with high Black and Hispanic populations.Controlling for hospital characteristics and case mix, hospitals with high Black and Hispanicpopulations (marginal effect size, 0.32; [95% CI, 0.17-0.47]; P < .001) and safety-net hospitals(marginal effect size, 0.42; [95% CI, 0.27-0.57]; P < .001) that were mandated to participate in 2019had higher probabilities of being penalized than hospitals with lower Black and Hispanic populationsand non–safety-net hospitals (Table).DiscussionDifferences in Medicare’s allocation of penalties were large and increased after 2 overlapping policychanges in ways that have implications for equity. First, Medicare allowed hospitals in lower-spendingareas to exit CJR after 2017; hospitals mandated to participate thereafter were penalized at higherTable. Characteristics of Hospitals Mandated to Participate in CJR and Marginal Effect Sizes for Penalization StatusVariableParticipation characteristics, No. (%)a Marginal effect size for penalization status (95% CI)b2016 2017 2018 2019 2017 2018 2019Total 674 702 389 396 NA NA NAPenalized 0 162 (23.1) 173 (44.5) 209 (52.8) NA NA NATeaching statusNonteaching 254 (37.7) 267 (38.0) 136 (35.0) 141 (35.6) 0 [Reference] 0 [Reference] 0 [Reference]Teaching 420 (62.3) 435 (62.0) 253 (65.0) 255 (64.4) −0.10 (−0.17 to −0.02) 0.06 (−0.06 to 0.17) 0.07 (−0.04 to 0.18)SizeSmall 227 (33.7) 239 (34.0) 120 (30.8) 119 (30.0) 0 [Reference] 0 [Reference] 0 [Reference]Medium 230 (34.1) 246 (35.0) 138 (35.5) 144 (36.4) −0.07 (−0.15 to 0.01) 0.13 (0.01 to 0.25) 0.14 (0.03 to 0.24)Large 217 (32.2) 217 (30.9) 131 (33.7) 133 (33.6) −0.06 (−0.15 to 0.03) 0.10 (−0.04 to 0.23) 0.16 (0.03 to 0.29)OwnershipPublic 90 (13.4) 92 (13.1) 37 (9.5) 37 (9.3) −0.07 (−0.19 to 0.05) −0.30 (−0.48 to −0.12) −0.09 (−0.26 to 0.08)Nonprofit 423 (62.8) 443 (63.1) 245 (63.0) 250 (63.1) −0.13 (−0.22 to −0.03) −0.27 (−0.40 to −0.15) −0.34 (−0.44 to −0.23)Private 161 (23.9) 167 (23.8) 107 (27.5) 109 (27.5) 0 [Reference] 0 [Reference] 0 [Reference]Geographic locationNortheast 143 (21.2) 147 (20.9) 131 (33.7) 132 (33.3) 0 [Reference] 0 [Reference] 0 [Reference]Midwest 141 (20.9) 146 (20.8) 26 (6.7) 26 (6.6) 0.08 (−0.02 to 0.18) 0.02 (−0.17 to 0.20) −0.05 (−0.23 to 0.14)South 207 (30.7) 215 (30.6) 165 (42.4) 168 (42.4) −0.03 (−0.12 to 0.06) −0.04 (−0.15 to 0.08) −0.06 (−0.17 to 0.04)West 183 (27.2) 194 (27.6) 67 (17.2) 70 (17.7) 0.00 (−0.09 to 0.09) 0.09 (−0.06 to 0.25) 0.25 (0.13 to 0.37)RuralityNonrural 650 (96.4) 641 (91.3) 363 (93.3) 370 (93.4) 0 [Reference] 0 [Reference] 0 [Reference]Rural 24 (3.6) 61 (8.7) 26 (6.7) 26 (6.6) −0.03 (−0.14 to 0.08) −0.04 (−0.26 to 0.19) −0.11 (−0.26 to 0.03)Race and ethnicityLower proportionof Black andHispanic patients540 (80.1) 562 (80.1) 299 (76.9) 304 (76.8) 0 [Reference] 0 [Reference] 0 [Reference]High proportionof Black andHispanic patientsc134 (19.9) 140 (19.9) 90 (23.1) 92 (23.2) 0.36 (0.25 to 0.46) 0.33 (0.19 to 0.49) 0.32 (0.17 to 0.47)Safety-net hospitalstatusNon–safety-nethospital540 (80.1) 562 (80.1) 300 (77.1) 305 (77.0) 0 [Reference] 0 [Reference] 0 [Reference]Safety-net hospital 134 (19.9) 140 (19.9) 89 (22.9) 91 (23.0) 0.34 (0.22 to 0.46) 0.33 (0.16 to 0.50) 0.42 (0.27 to 0.57)Abbreviations: CJR, Comprehensive Care for Joint Replacement Model;NA, not applicable.a Data are expressed as the number (percentage) of hospitals in the cohort. For example,in 2017, 435 teaching hospitals were mandated to participate (comprising 62.0%of mandatory participants in 2017). In 2018, 253 teaching hospitals were mandatedto participate (comprising 65.0% of mandatory participants in 2018).b Data are expressed as the marginal effect size (95% CI) of each hospital characteristicon penalization status, relative to the characteristic’s reference group.c Race and ethnicity were defined according to beneficiaries’ self-selected race andethnicity at the time of Medicare enrollment.JAMA Health Forum | Research Letter Equity Implications of the Comprehensive Care for Joint Replacement ModelJAMA Health Forum. 2022;3(12):e224455. doi:10.1001/jamahealthforum.2022.4455 (Reprinted) December 2, 2022 2/4Downloaded From: https://jamanetwork.com/ by a Washington University - St Louis User  on 02/05/2023rates. Second, Medicare lowered spending targets for high-risk hospitals by shifting from hospital-specific targets to multihospital shared targets that did not account for differences in medical orsocial case mix between hospitals.1,4 These lower spending benchmarks may have been lessattainable for safety-net hospitals and hospitals with high Black and Hispanic populations, in partbecause they serve patients who have greater needs engendered by systemic barriers to care andthus remain persistently high spending.5,6This study has limitations. The 2019 penalties are preliminary, although historically less than 5%of preliminary penalties become bonuses on finalization. In 2021, Medicare began adjustingbenchmarks for patients’ medical and social complexity; performance data after 2019 are notavailable due to COVID-19-related delays.1In this cross-sectional study, differences in the types of hospitals penalized under CJR werefound to have widened. Regional benchmarks in CJR may inadvertently serve an institutionalizedfunction of penalizing the safety-net hospitals.2 Policy makers should ensure that hospitals receiveachievable spending benchmarks to avoid widening disparities in care.ARTICLE INFORMATIONAccepted for Publication: September 28, 2022.Published: December 2, 2022. doi:10.1001/jamahealthforum.2022.4455Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022Shashikumar SA et al. JAMA Health Forum.Corresponding Author: Karen E. Joynt Maddox, MD, MPH, 660 S Euclid Ave, St Louis, MO 63110(kjoyntmaddox@wustl.edu).Author Affiliations: Cardiovascular Division, Department of Medicine, Washington University School of Medicinein St Louis, St Louis, Missouri (Shashikumar, Joynt Maddox); School of Public Health, Brown University, Providence,Rhode Island (Ryan); Center for Health Economics and Policy, Institute for Public Health, Washington Universityin St Louis, St Louis, Missouri (Joynt Maddox).Author Contributions: Mr Shashikumar had full access to all the data in the study and takes responsibility for theintegrity of the data and the accuracy of the data analysis.Concept and design: All authors.Acquisition, analysis, or interpretation of data: Shashikumar, Joynt Maddox.Drafting of the manuscript: Shashikumar.Figure. Proportion of Mandatory-Participation Hospitals Receiving Penalties Under Comprehensive Carefor Joint Replacement (CJR) Model, by Hospital CharacteristicsOverallSafety netMediumRuralWith high Black and Hispanic populationsSmallPrivateSouthNonprofitPublicTeachingMidwestWestLargeNortheast9585754565553525150Hospitals penalized, %Year2017 2018 2019By design, CJR did not levy penalties in 2016. For eachcharacteristic, data are plotted as the percentageof hospitals penalized relative to the number ofhospitals that were mandated to participate that year.For example, 20.5% of teaching hospitals that weremandated to participate in 2017 were penalized,and 51.2% of teaching hospitals that were mandatedto participate in 2019 were penalized.JAMA Health Forum | Research Letter Equity Implications of the Comprehensive Care for Joint Replacement ModelJAMA Health Forum. 2022;3(12):e224455. doi:10.1001/jamahealthforum.2022.4455 (Reprinted) December 2, 2022 3/4Downloaded From: https://jamanetwork.com/ by a Washington University - St Louis User  on 02/05/2023Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Shashikumar, Ryan.Obtained funding: Shashikumar.Supervision: Ryan, Joynt Maddox.Conflict of Interest Disclosures: Mr Shashikumar reported receiving grants from Sarnoff Cardiovascular ResearchFoundation outside the submitted work. Dr Joynt Maddox reported receiving grants from NIH, serving on theCentene Health Policy Advisory Council, and receiving research funding from Humana outside the submitted work.No other disclosures were reported.Funding/Support: Mr Shashikumar receives research support from the Sarnoff Cardiovascular ResearchFoundation. Dr Ryan receives research support from the National Institute on Aging (R01AG047932-06A1).Dr Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (R01HL143421).Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study;collection, management, analysis, and interpretation of the data; preparation, review, or approval of themanuscript; and decision to submit the manuscript for publication.REFERENCES1. Comprehensive Care for Joint Replacement Model. US Centers for Medicare & Medicaid Services. Published2022. Accessed March 30, 2022. https://innovation.cms.gov/innovation-models/cjr2. Shashikumar SA, Waken RJ, Luke AA, Nerenz DR, Joynt Maddox KE. Association of stratification by proportionof patients dually enrolled in Medicare and Medicaid with financial penalties in the Hospital-Acquired ConditionReduction Program. JAMA Intern Med. 2021;181(3):330-338. doi:10.1001/jamainternmed.2020.73863. Thirukumaran CP, Glance LG, Cai X, Kim Y, Li Y. Penalties and rewards for safety net vs non-safety net hospitalsin the first 2 years of the Comprehensive Care For Joint Replacement model. JAMA. 2019;321(20):2027-2030.doi:10.1001/jama.2019.51184. Wilcock AD, Barnett ML, McWilliams JM, Grabowski DC, Mehrotra A. Hospital responses to incentives inepisode-based payment for joint surgery: a controlled population-based study. JAMA Intern Med. 2021;181(7):932-940. doi:10.1001/jamainternmed.2021.18975. Figueroa JF, Zhou X, Jha AK. Characteristics and spending patterns of persistently high-cost Medicare patients.Health Aff (Millwood). 2019;38(1):107-114. doi:10.1377/hlthaff.2018.051606. Joynt Maddox KE, Shashikumar SA, Ryan AM. Medicare’s bundled payment models-progress and pitfalls.JAMA. 2022;327(18):1761-1762. doi:10.1001/jama.2022.6402JAMA Health Forum | Research Letter Equity Implications of the Comprehensive Care for Joint Replacement ModelJAMA Health Forum. 2022;3(12):e224455. doi:10.1001/jamahealthforum.2022.4455 (Reprinted) December 2, 2022 4/4Downloaded From: https://jamanetwork.com/ by a Washington University - St Louis User  on 02/05/2023

Equity implications of hospital penalties during 4 years of the Comprehensive Care for Joint Replacement model, 2016 to 2019

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Equity implications of hospital penalties during 4 years of the Comprehensive Care for Joint Replacement model, 2016 to 2019

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