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Unintended Consequences Of Health Care Reform: Impact Of Changes In Payor Mix On Patient Safety Indicators
*Alex Bartholomew1, *Alexander Zeymo2, *Kitty Chan3, *Nathan Aminpour1, *Ankit Mishra1, *Thomas DeLeire4, *Nawar Shara5, Waddah B Al-Refaie6
1Georgetown University Medical Center, Washington, DC;2MedStar Health Research Institute, Washington, DC;3MedStar Health Research Institue, Washington, DC;4Georgetown McCourt School of Public Policy, Washington, DC;5MedStar Health Research Institute and Georgetown University Medical Center, Washington, DC;6MedStar Georgetown University Hospital, Washington, DC

OBJECTIVE(S):
Medicaid expansion under the Affordable Care Act has raised concerns over the influx of medically and socially complex populations into healthcare systems. Whether increases in Medicaid and uninsured payor mix impacts hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare & Medicaid Services(CMS)-endorsed Patient Safety Indicators (PSI-90).
METHODS:
358 hospitals were identified using State Inpatient Databases (2012-2015) from three expansion (KY, MD, NJ) and two non-expansion (FL, NC) states. PSI-90 scores were calculated using AHRQ modules. Proportion of hospital Medicaid and uninsured patients was categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90.
RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion vs. non-expansion states (-5.9% vs. -4.7%, respectively; p=0.441) and across high SNB hospitals within expansion vs. non-expansion states (-3.9% vs. -5.2%, p=0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by five percent, they incurred significantly more safety events in expansion relative to non-expansion states (+1.87% vs. -14.0%, p = 0.013; Figure).
CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, CMS measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.


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