• Andrew S Oseran, Rishi K Wadhera, E John Orav, and Jose F Figueroa.
• Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.).
• Ann. Intern. Med. 2023 Apr 1; 176 (4): 480488480-488.

BackgroundMedicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.ObjectiveTo determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures.DesignCross-sectional.SettingPopulation-based.ParticipantsHospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program.MeasurementsUsing the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated.ResultsOf the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings.LimitationHospital performance measurement and risk adjustment differed slightly from those used by Medicare.ConclusionApproximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance.Primary Funding SourceLaura and John Arnold Foundation.

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