Neighborhood deprivation and Medicare expenditures for common surgical procedures


      • 30-day episode spending was $2654 higher among beneficiaries living in neighborhoods with high levels of deprivation compared to those in the least deprived.
      • Higher Medicare spending was in part driven by higher rates of readmissions (12.9% vs. 10.8%) and post-acute care (67.8% vs. 61.2%) among beneficiaries living in the most deprived neighborhoods.
      • The was a significant difference in payments between dual-eligible beneficiaries in the most and least deprived neighborhoods for the index hospitalization ($21,287 vs. $19,927).



      The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.


      Retrospective review of Medicare beneficiaries, age 65–99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.


      A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods.


      These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.


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        • National academies of sciences, engineering, and medicine
        Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors.
        The National Academies Press, Washington, DC2016
        • Joynt Maddox K.E.
        • Reidhead M.
        • Hu J.
        • et al.
        Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program.
        Health Serv Res. 2019; 54: 327-336
        • Gaskin D.J.
        • Zare H.
        • Vazin R.
        • Love D.
        • Steinwachs D.
        Racial and ethnic composition of hospitals' service areas and the likelihood of being penalized for excess readmissions by the medicare program.
        Med Care. 2018; 56: 934-943
        • Shih T.
        • Ryan A.M.
        • Gonzalez A.A.
        • Dimick J.B.
        Medicare's hospital readmissions reduction program in surgery may disproportionately affect minority-serving hospitals.
        Ann Surg. 2015; 261: 1027-1031
        • Roberts E.T.
        • Zaslavsky A.M.
        • McWilliams J.M.
        The value-based payment modifier: program outcomes and implications for disparities.
        Ann Intern Med. 2018; 168: 255-265
        • Zogg C.K.
        • Thumma J.R.
        • Ryan A.M.
        • Dimick J.B.
        Medicare's hospital acquired condition reduction program disproportionately affects minority-serving hospitals.
        Ann Surg. 2020; 271: 985-993
        • Nerenz D.R.
        • Austin J.M.
        • Deutscher D.
        • et al.
        (Adjusting quality measures for social risk factors can promote equity in health care.
        Health Aff. 2021; 40
        • Johnson K.J.
        • Maddox Joynt K.E.
        The Role of Social, Cognitive, and Functional Risk Factors in Medicare Spending for Dual and Nondual Enrollees. vol. 38. 2019: 569-576 (4)
        • Markovitz A.A.
        • Ellimoottil C.
        • Sukul D.
        • et al.
        Risk Adjustment may lessen penalties on hospitals treating complex cardiac patients under Medicare's bundled payments.
        Health Aff. 2017; 36: 2165-2174
        • Azap R.A.
        • Paredes A.Z.
        • Diaz A.
        • Hyer J.M.
        • Pawlik T.M.
        The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery.
        Surgery. 2020; 168: 868-875
        • Wadhwani S.I.
        • Beck A.F.
        • Bucuvalas J.
        • Gottlieb L.
        • Kotagal U.
        • Lai J.C.
        Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation.
        Am J Transplant. 2020; 20: 1597-1605
        • Diaz A.
        • Dalmacy D.
        • Hyer J.M.
        • Tsilimigras D.
        • Pawlik T.M.
        Intersection of social vulnerability and residential diversity: postoperative outcomes following resection of lung and colon cancer.
        J Surg Oncol. 2021; 124: 886-893
        • Ghirimoldi F.M.
        • Schmidt S.
        • Simon R.C.
        • et al.
        Association of socioeconomic area deprivation index with hospital readmissions after colon and rectal surgery.
        J Gastrointest Surg. 2021; 25: 795-808
        • Dickman S.L.
        • Woolhandler S.
        • Bor J.
        • McCormick D.
        • Bor D.H.
        • Himmelstein D.U.
        Health spending for low-, middle-, and high-income Americans.
        Health Aff. 2016; 35 (1963-2012): 1189-1196
        • Hu J.
        • Gonsahn M.D.
        • Nerenz D.R.
        Socioeconomic status and readmissions: evidence from an urban teaching hospital.
        Health Aff. 2014; 34: 778-785
        • Glance L.G.
        • Kellermann A.L.
        • Osler T.M.
        • Li Y.
        • Li W.
        • Dick A.W.
        Impact of risk adjustment for socioeconomic status on risk-adjusted surgical readmission rates.
        Ann Surg. 2016; 263: 698-704
        • Mehaffey J.H.
        • Hawkins R.B.
        • Charles E.J.
        • et al.
        Socioeconomic “distressed communities index” improves surgical risk-adjustment.
        Ann Surg. 2020; 271: 470-474
        • Crawford S.
        • Schold J.
        Association between geographic measures of socioeconomic status and deprivation and major surgical outcomes.
        Med Care. 2019; 57: 949-959
        • Kaye D.R.
        • Luckenbaugh A.N.
        • Oerline M.
        • et al.
        Understanding the costs associated with surgical care delivery in the medicare population.
        Ann Surg. 2020; 271: 23-28
        • Singh G.K.
        Area deprivation and widening inequalities in US mortality, 1969-1998.
        Am J Publ Health. 2003; 93: 1137-1143
        • Kind A.J.H.
        • Buckingham W.R.
        Making neighborhood-disadvantage metrics accessible—the neighborhood atlas.
        N Engl J Med. 2018; 378: 2456-2458
        • Grenda T.R.
        • Krell R.W.
        • Dimick J.B.
        Reliability of hospital cost profiles in inpatient surgery.
        Surgery. 2016; 159: 375-380
        • Scally C.P.
        • Thumma J.R.
        • Birkmeyer J.D.
        • Dimick J.B.
        Impact of surgical quality improvement on payments in medicare patients.
        Ann Surg. 2015; 262: 249-252
        • Kind A.J.
        • Jencks S.
        • Brock J.
        • et al.
        Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.
        Ann Intern Med. 2014; 161: 765-774
        • Miller D.C.
        • Gust C.
        • Dimick J.B.
        • Birkmeyer N.
        • Skinner J.
        • Birkmeyer J.D.
        Large variations in medicare payments for surgery highlight savings potential from bundled payment programs.
        Health Aff. 2011; 30: 2107-2115
        • Birkmeyer J.D.
        • Gust C.
        • Baser O.
        • Dimick J.B.
        • Sutherland J.M.
        • Skinner J.S.
        Medicare payments for common inpatient procedures: implications for episode-based payment bundling.
        Health Serv Res. 2010; 45: 1783-1795
        • Birkmeyer J.D.
        • Gust C.
        • Dimick J.B.
        • Birkmeyer N.J.
        • Skinner J.S.
        Hospital quality and the cost of inpatient surgery in the United States.
        Ann Surg. 2012; 255 (1): 1-5
        • Khullar D.
        • Zhang Y.
        • Kaushal R.
        Potentially preventable spending among high-cost medicare patients: implications for healthcare delivery.
        J Gen Intern Med. 2020; 35: 2845-2852
        • Johnson A.E.
        • Zhu J.
        • Garrard W.
        • et al.
        Area deprivation index and cardiac readmissions: evaluating risk-prediction in an electronic health record.
        J Am Heart Assoc. 2021; 10e020466
        • Zhang Y.
        • Li J.
        • Yu J.
        • Braun R.T.
        • Casalino L.P.
        Social determinants of health and geographic variation in medicare per beneficiary spending.
        JAMA Netw Open. 2021; 4e2113212
        • Cher B.A.Y.
        • Ryan A.M.
        • Hoffman G.J.
        • Sheetz K.H.
        Association of Medicaid eligibility with surgical readmission among Medicare beneficiaries.
        JAMA Netw Open. 2020; 3e207426
        • Byrd J.N.
        • Chung K.C.
        Evaluation of the merit-based incentive payment system and surgeons caring for patients at high social risk.
        JAMA Surg. Published online. 2021; (August 11)
        • Laraia B.A.
        • Karter A.J.
        • Warton E.M.
        • Schillinger D.
        • Moffet H.H.
        • Adler N.
        Place matters: neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE).
        Soc Sci Med. 2012; 74: 1082-1090
        • Diez Roux A.V.
        • Merkin S.S.
        • Arnett D.
        • et al.
        Neighborhood of residence and incidence of coronary heart disease.
        N Engl J Med. 2001; 345: 99-106
        • Jung D.
        • Kind A.
        • Robert S.
        • Buckingham W.
        • DuGoff E.
        Linking neighborhood context and health in community-dwelling older adults in the medicare advantage program.
        J Am Geriatr Soc. 2018; 66: 1158-1164
        • Shih T.
        • Ryan A.M.
        • Gonzalez A.A.
        • Dimick J.B.
        Medicare's hospital readmissions reduction program in surgery may disproportionately affect minority-serving hospitals.
        Ann Surg. 2015; 261: 1027-1031
        • Horwitz L.I.
        • Chang C.
        • Arcilla H.N.
        • Knickman J.R.
        Quantifying health systems investment in social determinants of health, by sector, 2017-2019.
        Health Aff. 2020; 39: 192-198
        • Young G.J.
        • Flaherty S.
        • Zepeda E.D.
        • Singh S.R.
        • Rosen Cramer G.
        Community benefit spending by tax-exempt hospitals changed little after ACA.
        Health Aff. 2018; 37: 121-124