Effect of cuts in medicare reimbursement on process and outcome of care for acute myocardial infarction patients

Background - The Balanced Budget Act ( BBA) of 1997 was designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. The objective of this study was to determine whether the process of care for acute myocardial infarction ( AMI) worsened to a greater degree in hospitals under increased financial strain from the BBA and whether vulnerable populations such as the uninsured were disproportionately affected. Methods and Results - We examined how process-of-care measures and in-hospital mortality for AMI patients changed in accordance with the degree of BBA-induced financial stress using data on 236 506 patients from the National Registry of Myocardial Infarction ( NRMI) and Medicare Cost Reports from 1996 to 2001. BBA-induced reductions in hospital net revenues were estimated at 1.5% ($2.9 million) for hospitals with low BBA impact and 3.2% ($ 3.7 million) for hospitals with a high impact in 1998, worsening to 2.2% ($ 4.4 million) and 4.7% ($6.0 million), respectively, by 2001. For both insured and uninsured patients in high-versus low-impact hospitals, there was no systematic worsening of time to thrombolytic therapy, balloon inflation, medication use on admission, medication use on discharge, or mortality. There was no systematic pattern of different treatment among the insured and uninsured. Operating margins decreased to a degree commensurate with the degree of revenue reduction in high-versus low-impact hospitals. Conclusions - BBA created a moderate financial strain on hospitals. However, process-of-care measures for both insured and uninsured patients with AMI were not appreciably affected by these revenue reductions. It is important to note that these results apply only to AMI patients; we do not know the degree to which these findings generalize to other conditions.