Medicare Value-Based Purchasing Program Yields Comparable 30-Day Mortality Rates Across Hospitals

No evidence was found of a differential change in 30-day mortality rates among all Medicare fee-for-service beneficiaries with targeted conditions at hospitals with high proportions of Black patients compared to other hospitals after implementing the Medicare Hospital Value-Based Purchasing (VBP) program, according to a study published in Health Affairs.

The researchers explained that US hospitals that care for a high proportion of Black adults often have limited resources, and prior studies have suggested that the quality of care may be worse at these sites. Consequently, CMS implemented the VBP program in 2011, which financially incentivizes improvements in care quality for common clinical conditions at low-performing hospitals. Early evaluations found that the program did not meaningfully improve 30-day mortality rates, and more recent studies showed that the program consistently and disproportionately penalized hospitals caring for mostly Black adults; this raised concerns that the program may unintentionally widen health outcome inequities over time.

To evaluate whether the VBP Program widened mortality disparities between these hospital groups, the researchers examined 30-day mortality rates among Medicare fee-for-service beneficiaries hospitalized between 2011 and 2018 for either acute myocardial infarction, pneumonia, or heart failure at hospitals caring for high proportions of Black adults compared with other hospitals.

The researchers found Gaps in outcomes widened in the subgroup of Black adults with pneumonia under the VBP Program. | Image Credit: Nuttapong punna - stock.adobe.com

They used CMS Hospital Compare to identify hospitals participating in the VBP Program. Also, the researchers used Medicare Provider Analysis and Review files to classify hospitals based on the proportion of all Medicare hospitalizations occurring among Black adults; Medicare Provider Analysis and Review data was also used to acquire patients’ race and to identify patients with a primary discharge diagnosis of heart failure, acute myocardial infarction, or pneumonia. Lastly, the 2020 American Hospital Association Annual Survey was used to obtain hospital characteristics, including size, teaching status, ownership, and location.

The researchers determined that 2908 hospitals participated in the VBP Program during the study period (2008-2018); of those that participated, 592 (20.4%) hospitals had high proportions of Black patients. They noted that hospitals with high proportions of Black patients were more likely than other hospitals to be large (271% vs 14.4%; P < .001), publicly owned (20.7% vs 10.8%; P < .001), and teaching hospitals (72.4% vs 61.2%; P < .001).

During the study period, risk-adjusted 30-day acute myocardial infarction mortality was higher at hospitals with high proportions of Black patients (adjusted odds ratio [aOR], 1.04). Before implementing the program, quarterly risk-adjusted 30-day acute myocardial infarction mortality rates decreased at hospitals with high proportions of Black patients (–0.08%), and the rates continued to decline after implementing the program (–0.02%). The researchers noted that similar patterns were observed at other hospitals, with a decrease in mortality during both the pre-VBP Program (–0.06%) and post-VBP Program (–0.03%) periods. Consequently, there was no differential change in risk-adjusted 30-day acute myocardial infarction mortality between hospitals with high proportions of Black patients and other hospitals after implementing the VBP Program (adjusted differential change, 0.03%).

Additionally, the researchers explained that the risk-adjusted 30-day heart failure mortality rate of hospitals with high proportions of Black patients was similar to that of other hospitals (aOR, 1.00). At hospitals with high proportions of Black patients, quarterly risk-adjusted 30-day heart failure mortality rates increased during the pre-VBP Program (0.06%) and then plateaued after program implementation in 2011 (–0.01%). Similarly, other hospitals experienced an increase in 30-day heart failure mortality before the VBP Program (0.07%), but mortality rates declined during the post–VBP Program period (–0.02%). Overall, there was no differential change in risk-adjusted 30-day heart failure mortality between hospitals with high proportions of Black patients and other hospitals after implementing the VBP Program (adjusted differential change, 0.02%).

Lastly, during the pre-VBP Program period, quarterly risk-adjusted 30-day pneumonia mortality rates increased at hospitals with high proportions of Black patients (0.02%) but then decreased during the post-VBP Program period (–0.08%). Similar patterns were displayed at other hospitals, with increasing pneumonia mortality before the VBP Program (0.03%), followed by a decrease after the program’s implementation (–0.07%). Consequently, VBP Program implementation was not associated with a differential change in 30-day pneumonia mortality between hospitals with high proportions of Black patients and other hospitals (adjusted differential change, –0.01%).

The researchers also evaluated how the VBP Program affected outcomes in Black versus White adults. After program implementation, they found no differential change in 30-day mortality between Black adults admitted to hospitals with high proportions of Black adults versus other hospitals for acute myocardial infarction or heart failure. Conversely, the program was associated with widening inequities in pneumonia mortality rates for Black adults.

The researchers acknowledged their study’s limitations, one being that they did not consider recent CMS efforts. Evidence has shown that pay-for-performance programs have not led to meaningful improvements in care delivery or outcomes; instead, they have often been regressive. In response, CMS prioritized health equity to improve national care quality and outcomes as newer value-based payment programs have been designed to address care delivery inequities. Consequently, the researchers suggested evaluating the impact of these new efforts.

“Future studies will need to evaluate how emerging CMS initiatives affect care delivery and outcomes, particularly at hospitals and practices that care for racial and ethnic minority populations,” the authors wrote.

Reference

Kyalwazi AN, Prihatha Narasimmaraj, Xu J, Song Y, Wadhera RK. Medicare’s value-based purchasing and 30-day mortality at hospitals caring for high proportions of Black adults. Health Affairs. 2024;43(1):118-124. doi:10.1377/hlthaff.2023.00740