Medicare's Hospital Readmissions Reduction Program in surgery may disproportionately affect minority-serving hospitals

In October 2012, the Centers for Medicare and Medicaid Services (CMS) began to reduce reimbursement to hospitals with “excessive” readmission rates for medical conditions through the Hospital Readmission Reduction Program (HRRP).1 The program will expand to hip and knee replacement in 2015,2 and is expected to incorporate other surgical procedures including cardiac surgery in the near future.3 Although well intentioned, many stakeholders are concerned that the HRRP will have unintended consequences for minority-serving hospitals, penalizing hospitals with the least resources. Other value-based purchasing policies, such as pay-for-performance, have drawn criticism for their potential to worsen health care disparities.4, 5 Whether minority-serving hospitals will be disproportionately impacted when the HRRP is expanded to surgery is unknown. Analysis of the medical conditions covered under the program suggests safety-net hospitals bear a disproportionate share of financial penalties.6 It is possible that similar disparities will be present in surgical populations. However, there are reasons to believe that HRRP penalties may be distributed differently for surgical conditions. Whereas patients with common medical conditions are often admitted to local hospitals where they initially present, surgical referral patterns are different. Frequently, large minority populations are referred to secondary or tertiary care hospitals, where the high volume of complex operations often translates to higher quality care. Consequently, minority-serving hospitals may not have higher readmission rates that translate to higher financial penalties. In this context, we sought to project the reduction in Medicare payments for hospitals if the HRRP is extended to cardiac surgery. Using data from national Medicare beneficiaries undergoing coronary artery bypass graft (CABG) surgery, we profiled hospitals based on the proportion of African-American patients to determine the extent to which HRRP penalties will affect minority-serving hospitals.