Medical home healthcare services in Taiwan, 2013-2020.

Taiwan has implemented a Medical Home Healthcare (MHHC) policy to provide home healthcare services to residents in need. First was the Ordinary Medical Home Healthcare (OMHHC) program in 1997 and then expanded to Integrated Medical Home Healthcare (IMHHC) in 2016. The OMHHC is provided care for residents with tubes at home or in institutions by physicians and nurses, and the IMHHC include additional professions, such as pharmacists and dentists. This study analyzed the longitudinal data from 2013 to 2020 with respect to overall home health services utilizations, and the type of services, and compared the differences between areas with and without healthcare shortages. Our results showed that the IMHHC program enhanced the accessibility of home healthcare to those in needs, especially those in healthcare shortage areas. However, some services in the IMHHC program may still have low utilization rates. It is necessary to investigate the potential barriers for residents to access those services.

The phosphatase DUSP22 inhibits UBR2-mediated K63-ubiquitination and activation of Lck downstream of TCR signalling.

DUSP22 is a dual-specificity phosphatase that inhibits T cell activation by inactivating the kinase Lck. Here we show that the E3 ubiquitin ligase UBR2 is a positive upstream regulator of Lck during T-cell activation. DUSP22 dephosphorylates UBR2 at specific Serine residues, leading to ubiquitin-mediated UBR2 degradation. UBR2 is also modified by the SCF E3 ubiquitin ligase complex via Lys48-linked ubiquitination at multiple Lysine residues. Single-cell RNA sequencing analysis and UBR2 loss of function experiments showed that UBR2 is a positive regulator of proinflammatory cytokine expression. Mechanistically, UBR2 induces Lys63-linked ubiquitination of Lck at Lys99 and Lys276 residues, followed by Lck Tyr394 phosphorylation and activation as part of TCR signalling. Inflammatory phenotypes induced by TCR-triggered Lck activation or knocking out DUSP22, are attenuated by genomic deletion of UBR2. UBR2-Lck interaction and Lck Lys63-linked ubiquitination are induced in the peripheral blood T cells of human SLE patients, which demonstrate the relevance of the UBR2-mediated regulation of inflammation to human pathology. In summary, we show here an important regulatory mechanism of T cell activation, which finetunes the balance between T cell response and aggravated inflammation.

Rural-urban disparities in the incidence and treatment intensity of periodontal disease among patients with diabetes.

Background: Diabetes threatens population health, especially in rural areas. Diabetes and periodontal diseases have a bidirectional relationship. A persistence of rural-urban disparities in diabetes may indicate a rural-urban difference in periodontal disease among patients with diabetes; however, the evidence is lacking. This retrospective study aimed to investigate rural-urban discrepancies in the incidence and treatment intensity of periodontal disease among patients who were newly diagnosed with type 2 diabetes in the year 2010. Methods: The present study was a retrospective cohort design, with two study samples: patients with type 2 diabetes and those who were further diagnosed with periodontal disease. The data sources included the 2010 Diabetes Mellitus Health Database at the patient level, the National Geographic Information Standardization Platform and the Department of Statistics, Ministry of Health and Welfare in Taiwan at the township level. Two dependent variables were a time-to-event outcome for periodontal disease among patients with type 2 diabetes and the treatment intensity measured for patients who were further diagnosed with periodontal disease. The key independent variables are two dummy variables, representing rural and suburban areas, with urban areas as the reference group. The Cox and Poisson regression models were applied for analyses. Results: Of 68,365 qualified patients, 49% of them had periodontal disease within 10 years after patients were diagnosed with diabetes. Compared to urban patients with diabetes, rural (HR = 0.83, 95% CI: 0.75-0.91) and suburban patients (HR = 0.86, 95% CI: 0.83-0.89) had a lower incidence of periodontal disease. Among 33,612 patients with periodontal disease, rural patients received less treatment intensity of dental care (Rural: RR = 0.87, 95% CI: 0.83, 0.92; suburban: RR = 0.93, 95% CI: 0.92, 0.95) than urban patients. Conclusion: Given the underutilization of dental care among rural patients with diabetes, a low incidence of periodontal disease indicates potentially undiagnosed periodontal disease, and low treatment intensity signals potentially unmet dental needs. Our findings provide a potential explanation for the persistence of rural-urban disparities in poor diabetes outcomes. Policy interventions to enhance the likelihood of identifying periodontal disease at the early stage for proper treatment would ease the burden of diabetes care and narrow rural-urban discrepancies in diabetes outcomes.

Rural-urban disparities in Oral Health-related Quality of Life for middle-aged and older adults with diabetes in Taiwan.

Background: Public health faces a significant challenge in reducing rural-urban disparities in diabetes. Since dietary control is part of the medical regimen for diabetes management, how diabetic patients perceive the impact of oral health on their quality of life is critical. The present study aimed to compare the Oral Health-related Quality of Life (OHRQoL) between rural and urban diabetic patients. Methods: The study design was cross-sectional. The study sample included 831 self-reported diabetic patients, extracted from the first wave of the new-cohort Taiwan Longitudinal Study on Aging survey (NC_TLSA) that comprised a nationally representative sample of community-dwelling adults aged 50 and above in Taiwan. The composite score generated from the Oral Health Impact Profile-7 (OHIP-7), which has seven questions, was used to construct two OHRQoL measures, the severity of perceived poor OHRQoL and the prevalence of poor OHRQoL. These two OHRQoL measures were treated as dichotomous variables. Multivariate logistic regression models were applied for analysis. Results: Rural diabetic patients had a higher likelihood of experiencing the severity of perceived poor OHRQoL than those in urban areas (OR = 2.40, 95% CI: 1.30-4.40). Although rural diabetic patients also had a higher prevalence of poor OHRQoL than urban diabetic patients, the difference was not significant (OR = 1.47, 95% CI: 0.95-2.28). Social determinants, such as education, are essential factors attributed to both OHRQoL measures. Conclusion: Overall, rural diabetes community-dwelling patients had a poorer OHRQoL than those in urban areas. Given a bidirectional relationship between oral health and diabetes, improving oral health in rural areas may be a critical avenue to improve the quality of diabetes care in rural areas.

Social determinants of ambulatory care sensitive conditions: a qualitative meta-synthesis based on patient perspectives.

Background: Hospitalizations or emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSC) are preventable but cost billions in modern countries. The objective of the study is to use a meta-synthesis approach based on patients' narratives from qualitative studies to reveal why individuals are at risk of ACSC hospitalizations or ED visits. Methods: PubMed, Embase, Cochrane Library, and Web of Science databases were utilized to identify qualified qualitative studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis were used for reporting the review. The thematic synthesis was used to analyze the data. Results: Among 324 qualified studies, nine qualitative studies comprising 167 unique individual patients were selected based on the inclusion/exclusion criteria. Through the meta-synthesis, we identified the core theme, four major themes, and the corresponding subthemes. Poor disease management, the core theme, turns individuals at risk of ACSC hospitalizations or ED visits. The four major themes contribute to poor disease management, including difficulties in approaching health services, non-compliance with medications, difficulties in managing the disease at home, and poor relationships with providers. Each major theme comprised 2-4 subthemes. The most cited subthemes are relative to upstream social determinants, such as financial constraints, inaccessible health care, low health literacy, psychosocial or cognitive constraints. Conclusion: Without addressing upstream social determinants, socially vulnerable patients are unlikely to manage their disease well at home even though they know how to do it and are willing to do it. Trial registration: National Library of Medicine, with ClinicalTrials.gov, Identifier: NCT05456906. https://clinicaltrials.gov/ct2/show/NCT05456906.

The Role of Sfp1 in Candida albicans Cell Wall Maintenance.

The cell wall is the first interface for Candida albicans interaction with the surrounding environment and the host cells. Therefore, maintenance of cell wall integrity (CWI) is crucial for C. albicans survival and host-pathogen interaction. In response to environmental stresses, C. albicans undergoes cell wall remodeling controlled by multiple signaling pathways and transcription regulators. Here, we explored the role of the transcription factor Sfp1 in CWI. A deletion of the SFP1 gene not only caused changes in cell wall properties, cell wall composition and structure but also modulated expression of cell wall biosynthesis and remodeling genes. In addition, Cas5 is a known transcription regulator for C. albicans CWI and cell wall stress response. Interestingly, our results indicated that Sfp1 negatively controls the CAS5 gene expression by binding to its promoter element. Together, this study provides new insights into the regulation of C. albicans CWI and stress response.

Geographic variation in Medicare home health expenditures.

OBJECTIVES: To quantify geographic variation in home health expenditures per Medicare home health beneficiary and investigate factors associated with this variation. STUDY DESIGN: Retrospective study design analyzing US counties in which at least 1 home health agency served 11 or more beneficiaries in 2016. Several sources of 2016 national public data were used. METHODS: The key variable is county-level Medicare home health expenditures per home health beneficiary. Counties were grouped into quintiles based on per-beneficiary expenditures. Analyses included calculation of coefficients of variation, computation of the ratio of 90th percentile to 10th percentile in expenditures, and linear regression predicting expenditure. The control variables included characteristics of patients, agencies, and communities. RESULTS: Significant variation in home health expenditures was identified across county quintiles, with a 90th-to-10th-percentile expenditure ratio of 2.5. The percentage of for-profit agencies in the lowest quintile was 15.7 compared with 81.7 in the highest quintile of spending. Unadjusted spending differed by $3864 (95% CI, $3793-$3936), compared with $3611 (95% CI, $3514-$3708) in the adjusted model, between counties in spending quintiles 1 and 5. Although state fixed effects explained nearly 20% of the variation in home health expenditures, 42% of the variation remained unexplained. CONCLUSIONS: Home health care exhibits considerable unwarranted variation in per-patient expenditures across counties, signifying inefficiency and waste. Given the expected growth in home health demand, strategies to reduce unwarranted geographic variation are needed.

Relationship between political partisanship and COVID-19 deaths: future implications for public health.

BACKGROUND: COVID-19 has impacted more than 200 countries. However in the USA, the response to the COVID-19 pandemic has been politically polarized. The objective of this study is to investigate the association between political partisanship and COVID-19 deaths rates in the USA. METHODS: This study used longitudinal county-level panel data, segmented into 10 30-day time periods, consisting of all counties in the USA, from 22 January 2020 to 5 December 2020. The outcome measure is the total number of COVID-19 deaths per 30-day period. The key explanatory variable is county political partisanship, dichotomized as Democratic or Republican. The analysis used a ZINB regression. RESULTS: When compared with Republican counties, COVID-19 death rates in Democratic counties were significantly higher (IRRs ranged from 2.0 to 18.3, P < 0.001) in Time 1-Time 5, but in Time 9-Time10, were significantly lower (IRRs ranged from 0.43 to 0.69, P < 0.001). CONCLUSION: The reversed trend in COVID-19 death rates between Democratic and Republican counties was influenced by the political polarized response to the pandemic. The findings support the necessity of evidence-based public health leadership and management in maneuvering the USA out of the current COVID-19 pandemic and prepare for future public health crises.

Cost and Effectiveness of Long-Term Care Following Integrated Discharge Planning: A Prospective Cohort Study.

Little is known about the effects of seamless hospital discharge planning on long-term care (LTC) costs and effectiveness. This study evaluates the cost and effectiveness of the recently implemented policy from hospital to LTC between patients discharged under seamless transition and standard transition. A total of 49 elderly patients in the standard transition cohort and 119 in the seamless transition cohort were recruited from November 2016 to February 2018. Data collected from medical records included the Multimorbidity Frailty Index, Activities of Daily Living Scale, and Malnutrition Universal Screening Tool during hospitalization. Multiple linear regression and Cox regression models were used to explore risk factors for medical resource utilization and medical outcomes. After adjustment for effective predictors, the seamless cohort had lower direct medical costs, a shorter length of stay, a higher survival rate, and a lower unplanned readmission rate compared to the standard cohort. However, only mean total direct medical costs during hospitalization and 6 months after discharge were significantly (p < 0.001) lower in the seamless cohort (USD 6192) compared to the standard cohort (USD 8361). Additionally, the annual per-patient economic burden in the seamless cohort approximated USD 2.9-3.3 billion. Analysis of the economic burden of disability in the elderly population in Taiwan indicates that seamless transition planning can save approximately USD 3 billion in annual healthcare costs. Implementing this policy would achieve continuous improvement in LTC quality and reduce the financial burden of healthcare on the Taiwanese government.

Financial Performance of Hospitals in the Appalachian Region Under the Hospital Readmissions Reduction Program and Hospital Value-Based Purchasing Program.

PURPOSE: The Hospital Readmission and Reduction Program (HRRP) and Hospital Value-Based Purchasing Program (HVBP) propose to improve quality of patient care by either rewarding or penalizing hospitals through inpatient reimbursement. This study analyzes the effect of both programs on profitability of hospitals located in the Appalachian Region (AR) compared to hospitals in Appalachian states and the rest of the United States. METHODS: This study used a retrospective research design with a longitudinal unbalanced panel dataset from 2008 to 2015. Hospitals participating in both HRRP and HVBP during this time frame were included in the study. A difference-in-difference model with hospital-level fixed effects, controlling for hospital and market characteristics, was used to determine effects of both programs on profitability of hospitals serving the AR, Appalachian states, and the rest of the United States. FINDINGS: After implementation of HRRP and HVBP, only hospitals located in Appalachian states experienced a significant decrease in operating margin (-1.14 percentage points). Unexpectedly, during the same time period, total margin increased significantly for hospitals located in the AR (1.05 percentage points), Appalachian states (1.71 percentage points), and the rest of the United States (2.38 percentage points). CONCLUSIONS: HRRP and HVBP financially incentivize hospitals to focus efforts on improving patient care. The programs may not have the anticipated results. Increases in total margin for all hospitals during the study period indicate access to nonpatient revenues, offsetting the financial penalties from both programs. This revenue source may undermine the program's objectives of delivering value and achieving quality outcomes.

Deaths From COVID-19 in Rural, Micropolitan, and Metropolitan Areas: A County-Level Comparison.

PURPOSE: The United States has experienced a surge of COVID-19 cases and deaths. Regardless of the overall increase in the prevalence and mortality, there are disagreements about the consequences of exposure and contracting COVID-19, specifically in rural areas. Rural areas have inherent characteristics that increase their vulnerability to contracting COVID-19. The objective of this study was to investigate the differences in death rates from COVID-19 between urban and rural areas in the United States. METHODS: This study used county-level data. The data set consisted of confirmed COVID-19 cases and deaths along with county-level demographics. The sample consisted of all counties in the 50 US states and DC. Counties were designated as metropolitan, micropolitan, and rural. A zero-inflated negative binomial regression was used to estimate county-level number of deaths conditional on contracting COVID-19. The study focused on COVID-19-related mortality from February 10, 2020, to June 12, 2020. FINDINGS: After controlling for county-level characteristics, the rate of COVID-19 deaths was 70.3% (P < .001) for rural counties and 53.4% (P < .001) for micropolitan counties, both significantly lower than metropolitan counties during the study time period. CONCLUSION: Over time, rural geography and social isolation may not provide sustainable protection to rural residents from the pandemic. The slow progression provides rural areas additional time and opportunity to learn from the experiences in urban areas that were most affected. Rural areas need to be proactive and develop prevention strategies and response plans to manage and control the spread of COVID-19.

How Have Hospitals in the Mississippi Delta Fared Under the 2019 Revised Hospital Readmissions Reduction Program?

In 2013, the Centers for Medicare and Medicaid Services (CMS) implemented the Hospital Readmissions Reduction Program (2013 HRRP), which financially penalized hospitals if their 30-day readmissions were higher than the national average. Without adjusting for socioeconomic status of patients, the 2013 HRRP overly penalized hospitals caring for the poor, especially hospitals in the Mississippi Delta region, one of the poorest regions in the U.S. In 2019, CMS revised the HRRP (2019 Revised HRRP) to stratify hospitals into quintiles based on the proportion of patients that are dual-eligible Medicare and Medicaid beneficiaries. This study aimed to examine the effect of the 2019 Revised HRRP on financial penalties for Delta hospitals using a difference-in-difference (DID) approach with data from the 2018 and 2019 HRRP Supplemental Files. The DID analysis found that relative to non-Delta hospitals, penalties in Delta hospitals were reduced by 0.08 percentage points from 2018 to 2019 (95% CI for the coefficient: -0.15, -0.01; P = .02), and the probability of a penalty was reduced by 6.64 percentage points (95% CI for the coefficient: -9.54, -3.75; P < .001). The stratification under the 2019 Revised HRRP is an important first step in reducing unfair penalties to hospitals that serve poor populations.

Reply to "Risk adjustment in Home Health Care CAHPS".

The authors of "CMS HCC Risk Scores and Home Health Patient Experience Measures" respond to a letter to the editor.

Quality Performance of Rural and Urban Home Health Agencies: Implications for Rural Add-On Payment Policies.

PURPOSE: To examine the differences in quality performance among agencies in urban areas and those in high utilization, low population density, and all other rural areas, defined in the Bipartisan Budget Act (BBA). METHODS: We conducted a retrospective study using 2015 data: the Home Health Compare, the Home Health Agency Utilization and Payment Use, the Provider of Services, and the Area Health Resources Files, and a file with rural categories in BBA. The quality measures included (1) hospitalizations, (2) emergency visits, (3) patient experience, (4) composite scores for improvement in activities of daily living (ADL), (5) improvement in pain and treating symptoms, (6) preventing harm, and (7) treating wounds and preventing pressure sores. We applied weighted least squares regression. FINDINGS: Among all quality measures, differences in emergency visits of the 3 rural categories from urban agencies were the largest. The adjusted mean emergency visit for urban agencies was 12.42%, with agencies in rural areas having 1.01-1.96 percentage points higher rates than urban agencies (95% CI: 0.72-1.29 for high utilization areas, 95% CI: 0.51-3.42 for low population areas, and 95% CI: 1.28-1.78 for all other areas). CONCLUSIONS: The differences in the quality of care among agencies in 3 categories of rural areas were small, except for emergency visits. Given policies to reduce rural add-on payments for home health services, continued monitoring of the services provided and the quality of care by home health agencies in rural areas is recommended.

Regulation of Dual-Specificity Phosphatase (DUSP) Ubiquitination and Protein Stability.

Mitogen-activated protein kinases (MAPKs) are key regulators of signal transduction and cell responses. Abnormalities in MAPKs are associated with multiple diseases. Dual-specificity phosphatases (DUSPs) dephosphorylate many key signaling molecules, including MAPKs, leading to the regulation of duration, magnitude, or spatiotemporal profiles of MAPK activities. Hence, DUSPs need to be properly controlled. Protein post-translational modifications, such as ubiquitination, phosphorylation, methylation, and acetylation, play important roles in the regulation of protein stability and activity. Ubiquitination is critical for controlling protein degradation, activation, and interaction. For DUSPs, ubiquitination induces degradation of eight DUSPs, namely, DUSP1, DUSP4, DUSP5, DUSP6, DUSP7, DUSP8, DUSP9, and DUSP16. In addition, protein stability of DUSP2 and DUSP10 is enhanced by phosphorylation. Methylation-induced ubiquitination of DUSP14 stimulates its phosphatase activity. In this review, we summarize the knowledge of the regulation of DUSP stability and ubiquitination through post-translational modifications.

The Transcription Factor Sfp1 Regulates the Oxidative Stress Response in Candida albicans.

Candida albicans is a commensal that inhabits the skin and mucous membranes of humans. Because of the increasing immunocompromised population and the limited classes of antifungal drugs available, C. albicans has emerged as an important opportunistic pathogen with high mortality rates. During infection and therapy, C. albicans frequently encounters immune cells and antifungal drugs, many of which exert their antimicrobial activity by inducing the production of reactive oxygen species (ROS). Therefore, antioxidative capacity is important for the survival and pathogenesis of C. albicans. In this study, we characterized the roles of the zinc finger transcription factor Sfp1 in the oxidative stress response against C. albicans. A sfp1-deleted mutant was more resistant to oxidants and macrophage killing than wild-type C. albicans and processed an active oxidative stress response with the phosphorylation of the mitogen-activated protein kinase (MAPK) Hog1 and high CAP1 expression. Moreover, the sfp1-deleted mutant exhibited high expression levels of antioxidant genes in response to oxidative stress, resulting in a higher total antioxidant capacity, glutathione content, and glutathione peroxidase and superoxide dismutase enzyme activity than the wild-type C. albicans. Finally, the sfp1-deleted mutant was resistant to macrophage killing and ROS-generating antifungal drugs. Together, our findings provide a new understanding of the complex regulatory machinery in the C. albicans oxidative stress response.

The small GTPase Rhb1 is involved in the cell response to fluconazole in Candida albicans.

Candida albicans is an important fungal pathogen in humans. Rhb1 is a small GTPase of the Ras superfamily and is conserved from yeasts to humans. In C. albicans, Rhb1 regulates the expression of secreted protease 2, low nitrogen-mediated morphogenesis, and biofilm formation. Moreover, our previous studies have indicated that Rhb1 is associated with the target of rapamycin (TOR) signaling pathway. In this study, we further explored the relationship between Rhb1 and drug susceptibility. The RHB1 deletion mutant exhibited reduced fluconazole susceptibility, and this phenotype occurred mainly through the increased gene expression and activity of efflux pumps. In addition, Mrr1 and Tac1 are transcription factors that can activate efflux pump gene expression. However, the RHB1 deletion, RHB1/MRR1 and RHB1/TAC1 double deletion mutants had no significant differences in efflux pump gene expression and fluconazole susceptibility, suggesting that Rhb1-regulated efflux pump genes do not act through Mrr1 and Tac1. We also showed that membrane localization is crucial for Rhb1 activity in response to fluconazole. Finally, Rhb1 was linked not only to the TOR but also to the Mkc1 mitogen-activated protein kinase signaling pathway in response to fluconazole. In sum, this study unveiled a new role of Rhb1 in the regulation of C. albicans drug susceptibility.

CMS HCC risk scores and home health patient experience measures.

OBJECTIVES: To understand the association between agency-level CMS Hierarchical Condition Categories (HCC) risk scores and patient experience measures for home health. STUDY DESIGN: This was a cross-sectional study. METHODS: We extracted variables from the 2014 Medicare Provider Utilization and Payment Data for Home Health Agencies and Home Health Compare file. We applied fixed-effects models for the analyses. Our dependent variables included both global and composite patient experience measures. The 2 global patient experience measures were the patient's overall rating of care provided by the agency (rating) and the patient's willingness to recommend the home health agency to others (recommendation). The 3 composite patient experience measures were how often the patient felt the provider gave care in a professional way (professional way), how well the home health team communicated with the patient (communication), and whether the home health team discussed medicines, pain, and home safety with the patient (discussion). RESULTS: Increased agency-level CMS HCC risk scores were negatively associated with all patient experience measures: rating (-2.04; P ≤.001), recommendation (-2.75; P <.001), professional way (-1.56; P <.001), communication (-1.67; P <.001), and discussion (-1.69; P ≤.001). Several covariates, including the percentage of racial/ethnic minority beneficiaries, ownership of the agency, and number of tenured years with the Medicare program, were significantly associated with patient experience measures. CONCLUSIONS: A negative association exists between CMS HCC risk scores and patient experience measures. To avoid unintended consequences, patient experience measures need further risk adjustment under the CMS 5-star patient survey rating system and the Home Health Value-Based Purchasing pilot program.

Understanding factors associated with readmission disparities among Delta region, Delta state, and other hospitals.

OBJECTIVES: To understand the factors that potentially account for differences in 30-day readmission ratios for pneumonia, heart failure, and acute myocardial infarction (AMI) among hospitals in the Mississippi Delta region (Delta region), in Delta states excluding the hospitals in the Delta region (Delta state), and in the rest of the nation (other). STUDY DESIGN: A longitudinal study design from 2013 to 2016. METHODS: The dependent variables were 30-day readmission ratios for AMI, heart failure, and pneumonia. The key independent variables were 2 hospital categories (Delta region and Delta state), year dummies for 2014-2016, and the interactions among hospital categories and year dummies. We conducted 2 analyses for each study condition by estimating models with and without controls for hospital and community characteristics. RESULTS: The coefficients for the interactions among year dummies and Delta region and Delta state hospitals were negative, indicating that Delta region and Delta state hospitals had higher reductions in readmissions than did other hospitals. After controlling for hospital and community characteristics, the disparities in readmissions for pneumonia and AMI in 2013 between Delta region and other hospitals were weakened (P >.05). Major teaching hospitals and percentage of black population were positively associated with readmissions for all study conditions (P values ranged from <.05 to <.001). CONCLUSIONS: Disparities in 30-day readmissions for the study conditions among Delta region, Delta state, and other hospitals were reduced under the Hospital Readmissions Reduction Program (HRRP). However, community factors that are not currently used for adjustment in HRRP were associated with readmission ratios. Revisions of HRRP should consider including community characteristics in risk adjustment models.

Financial Performance of Hospitals in the Mississippi Delta Region Under the Hospital Readmissions Reduction Program and Hospital Value-based Purchasing Program.

BACKGROUND: Previous studies showed that the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-based Purchasing Program (HVBP) disproportionately penalized hospitals caring for the poor. The Mississippi Delta Region (Delta Region) is among the most socioeconomically disadvantaged areas in the United States. The financial performance of hospitals in the Delta Region under both HRRP and HVBP remains unclear. OBJECTIVE: To compare the differences in financial performance under both HRRP and HVBP between hospitals in the Delta Region (Delta hospitals) and others in the nation (non-Delta hospitals). RESEARCH DESIGN: We used a 7-year panel dataset and applied difference-in-difference models to examine operating and total margin between Delta and non-Delta hospitals in 3 time periods: preperiod (2008-2010); postperiod 1 (2011-2012); and postperiod 2 (2013-2014). RESULTS: The Delta hospitals had a 0.89% and 4.24% reduction in operating margin in postperiods 1 and 2, respectively, whereas the non-Delta hospitals had 1.13% and 1% increases in operating margin in postperiods 1 and 2, respectively. The disparity in total margins also widened as Delta hospitals had a 1.98% increase in postperiod 1, but a 0.30% reduction in postperiod 2, whereas non-Delta hospitals had 1.27% and 2.28% increases in postperiods 1 and 2, respectively. CONCLUSIONS: The gap in financial performance between Delta and non-Delta hospitals widened following the implementation of HRRP and HVBP. Policy makers should modify these 2 programs to ensure that resources are not moved from the communities that need them most.