1. One-quarter of top-performing quintile hospitals were reclassified to a lower performance group when Medicare Advantage beneficiaries were included compared to fee-for-service Medicare only.

2. One-quarter of the lowest-performing quintile hospitals were reclassified to a higher performance group when Medicare Advantage beneficiaries were included compared to fee-for-service Medicare only.

Evidence Rating Level: 2 (Good)

Study Rundown: The Centers for Medicare and Medicaid Services (CMS) has implemented value-based programs which link hospital performance on quality measures to payment with the aim of incentivizing health systems to improve. In this cross-sectional study, the median 30-day risk-adjusted rates of hospital readmission for acute myocardial infarction (AMI), heart failure, chronic obstructive pulmonary disease (COPD), and pneumonia were greater for fee-for-service (FFS) Medicare beneficiaries only compared to FFS Medicare plus Medicare Advantage (MA). The median 30-day risk-adjusted mortality rates for AMI, heart failure, and pneumonia was greater for FFS Medicare beneficiaries only compared to FFS Medicare plus MA. However, the 30-day risk-adjusted mortality rates for COPD were the same for both groups. In performance rankings, about a quarter of hospitals ranked in the top quintiles based on readmission were reclassified to lower quintiles when including FFS Medicare and MA. Conversely, about a quarter of hospitals ranked in lower quintiles were reclassified to higher quintiles when including MA beneficiaries for hospital readmission for the observed conditions. The results were similar for the reclassification of hospital mortality performance. Hospitals with a higher proportion of MA beneficiaries were seen to have the greatest improvement in ranking if outcomes were evaluated across all Medicare beneficiaries. A limitation of this study is that the sample included only a small number of records and was limited to four medical conditions, which makes the results of this study more difficult to generalize to other populations.

Click to read the study in AIM

Relevant Reading: Medicare spending on drugs with accelerated approval

In-Depth [cross-sectional study]: This cross-sectional study examined the effects of including MA and FFS Medicare on the hospital performance rankings for AMI, heart failure, COPD, and pneumonia compared to FFS Medicare beneficiaries alone. The data for this study was obtained through the 100% Medicare FFS Inpatient Claim File and 100% Medicare Inpatient Encounter File from 2018 to identify hospital stays among Medicare beneficiaries aged 65 years or older with diagnoses of AMI, heart failure, COPD, or pneumonia and the associated readmission and mortality measures. The comparison of FFS Medicare versus FFS Medicare plus MA for median 30-day risk-adjusted hospital readmission rates for AMI was 15.9% vs. 15.4%, heart failure was 21.9% vs. 21.2%, COPD was 19.9% vs. 19.1%, and pneumonia was 17.0% vs. 16.4%, respectively. The comparison of FFS Medicare versus FFS Medicare plus MA for median 30-day risk-adjusted mortality rates for AMI was 12.8% vs. 12.4%, heart failure was 11.1% vs. 10.8%, COPD was 8.3% vs. 8.3%, and pneumonia was 14.9% vs. 14.6%, respectively. The reclassification of performance ranking based on quintiles was similar for hospital readmission and mortality for all four conditions. A quarter of top quintile hospitals were reclassified to a lower quintile for FFS Medicare plus MA compared to FFS Medicare alone. Safety-net status was associated with the worsening of hospital readmission rank when all Medicare beneficiaries were included in the evaluation. Hospital ownership status, size, and teaching status did not significantly change hospital readmission rankings with the inclusion of MA beneficiaries. In summary, the results of this study suggest that the current Medicare value-based program has a limited assessment of hospital performance.

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