The Association Between Residential Segregation and Hospital Readmissions Penalties Open Access
Henry, Antonio (Spring 2022)
Published
Abstract
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based program that encourages hospitals to improve care coordination and patient outcomes by applying financial penalties to hospitals identified as having excess 30-day unplanned readmission rates. Unfortunately, hospitals serving in the areas experiencing concentrated disadvantage are suffering the worst penalties. Historically, structural racism and socioeconomic inequities disproportionately expose Black Americans to these areas- a process that can be explored via racial residential segregation (RRS). The objective of this study was to investigate the association between RRS and hospital readmission penalties.
We used census tract and county level population counts by race from the 2020 Census to create the dissimilarity index measure for each county. Readmission penalty data was obtained from the CMS Hospital General information file via the Kaiser Family Foundation. County and hospital covariates were merged from the 2020-21 Area Health Resources Files and 2019 American Hospital Association Annual Survey. Bivariate analyses compared average readmission penalties across hospitals in low (HL), moderate (HM) and highly (HH) segregated counties. Generalized linear regression was used to estimate marginal effects, or the percentage point (ppt) difference in payment reductions between HL and HM/ HH. We considered a p-value of .05 as significant and analyses were performed using STATA.
The hospitals in the sample excluded those located in Maryland as well as cancer, rehabilitation, psychiatric, critical access, long-term care, and public-federal hospitals because they are exempt from the policy (n = 2,985). HM (n = 2,077) experienced a .12-ppt greater reduction in Medicare payments due to excess 30-day readmissions compared to HL (n = 423; p <.001). HH (n = 485) experienced an even greater reduction (.17 ppt; p<.001). Controlling for county-level covariates attenuated this relationship.
Our findings are congruous with research stating areal factors are associated with inequities in hospital readmission penalties. Policies that acknowledge structural racism and other areal factors should be considered as a mechanism to eliminate inequities in financial penalties among hospitals Thus, adding RRS to risk-adjustment acknowledges the detrimental impact of structural racism on the healthcare system.
Table of Contents
Table of Contents
CHAPTER I: INTRODUCTION
Research Justification, Objective, & Approach
CHAPTER II: LITERATURE REVIEW
HRRP Risk Adjustment
Racial Residential Segregation
Theoretical Framework
Mechanisms connecting Racial Residential Segregation to Hospital Readmissions Penalties
CHAPTER III: METHODS
Data
Analytic Sample
Measurement & Constructs
Focal Relationship
Confounders
Measurement
Hypothesis
Analytic Plan
CHAPTER IV: RESULTS
Descriptive Statistics
Bivariate Analysis
Regression Analyses
CHAPTER V: DISCUSSION
Summary
Comparisons with previous literature
Strengths & Limitations
Implications
Recommendations for Future Research
REFERENCES
Appendices
Appendix A: The Dissimilarity Index
Appendix B: Covariates Correlation Matrix
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