Do Medicare Hospital Admit a Representative Number of Beneficiaries Based on Their Respective Market Areas?

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Racial inequalities—and their impact on health outcomes—can be influenced by treatment differences due to a change in clinical practices according to location, implicit bias, limited access to care, social determinants of health, and systemic and historical racism.

Over the years, there has been a larger light being shined on how lower-quality care in segregated communities can result in poor health outcomes; when it comes to Black or African-American patients, there is limited information as to why the highest patient admission rates exist due to these patients from the same communities being admitted to different hospitals, or because hospital market are made up of segregated communities.

A cross-sectional study published in JAMA Network Open¹ sought to answer the following question: Do local acute care hospitals admit representative proportions of Black Medicare fee-for-service beneficiaries based on their market areas? The investigators’ goal was to design a novel local hospital segregation (LHS) index that measures whether a hospital’s racial pattern of admission differs from the racial composition of its market (as measured by driving time).

In order for Medicare claims to be utilized, they must first be approved by the Center for Medicare & Medicaid Services (CMS) under a data use agreement, which they were. The study investigators used the 2019 Medicare Provider Analysis and Review (MedPAR) file of inpatient data, the 2019 Medicare Master Beneficiary Summary File, and the 2019 American Hospital Association Survey in order to create a local hospital segregation (LHS) index. The LHS measures the spatial patterns of where Medicare enrollees live, and it’s important to keep in mind that it presumes that pre-existing patterns of residential segregation exist.

When it came to the hospitals, they were evaluated by the composition of Medicare enrollees who reside in the hospital’s market area; they were then compared hospitalization racial compositions with the market area composition. Their zip code markets were considered the racial makeup of a hospital’s admissions, along with the racial composition of the hospital’s market.

From November 2022 to January 2024, the study investigators assessed the enrollees that consisted of Medicare fee-for-service individuals 65 years of age or older that not only resided in the 48 contiguous states with at least one hospitalization, but at a hospital that accommodated at least 200 hospitalizations as well.

Overall, in a sample consisting of 1,991 acute care hospitals, 4,870,252 patients (mean [SD] age, 77.7 [8.3] years; 2,822,006 [56.0%] female) were treated, consisting of 597,564 Black patients (11.9%), 129,376 Asian patients (2.6%), 11,435 American Indian or Alaska Native patients (0.2%), 395,397 Hispanic patients (7.8%), and 3,818,371 White patients (75.8%). Half of the hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) presented a negative LHS score (includes admitting fewer Black patients relative to their market area) while 1,113 hospitals (45.0%) demonstrated a positive LHS (by admitting more Black patients relative to their market area). Out of all the hospitals, 79.4% of them displayed racial admission patterns considerably different from their market.

Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% confidence interval, 0.10 to 0.38), where in NY, NY; Chicago, IL; and Detroit, IL, hospital referral regions presented the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21 respectively.

In other words, even when controlling for residential segregation, the findings note that hospital segregation is still present and taking place in US hospitals.

Due to these results, the investigators concluded that, “In this cross-sectional study using a national sample of acute care hospitals in 2019, we used a novel measure of LHS to capture the sorting of patients who lived in the same markets to different hospitals. The LHS index could be leveraged by policy makers and clinical leaders to inform payment reform and hospital quality scores, thereby increasing equitable access to high-quality hospitals.”

Reference

1. Akré EL, Chyn D, Carlos HA, Barnato AE, Skinner J. Measuring Local-Area Racial Segregation for Medicare Hospital Admissions. JAMA Netw Open. 2024;7(4):e247473. doi:10.1001/jamanetworkopen.2024.7473