Changes to Racial Disparities in Readmission Rates After Medicare’s Hospital Readmissions Reduction Program Within Safety-Net and Non–Safety-Net Hospitals

IMPORTANCE: Although readmission rates are declining under Medicare’s Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions. OBJECTIVE: To examine disparities in readmission rates between white and black patients discharged from safety-net or non–safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions. DESIGN, SETTING, AND PARTICIPANTS: Cohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non–safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018. MAIN OUTCOMES AND MEASURES: Trends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods. RESULTS: The study sample included 58 237 056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, −0.07 to 0.10]; P = .74). Within non–safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted. CONCLUSIONS AND RELEVANCE: Findings from this study suggest that disparities are widening within safety-net hospitals, specifically for non–HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.