Study examines patient experience at safety-net hospitals

A study suggests that safety-net hospitals (SNHs), which typically care for poor patients, performed more poorly than other hospitals on nearly every measure of patient experience and that could have financial consequences as hospital payments are connected to performance, according to a report published Online First by Archives of Internal Medicine.

Value-based purchasing (VBP), a program run by the Centers for Medicare and Medicaid Services (CMS), now ties part of each hospital's payments to its performance on a set of quality measures. Under the program, about 1 percent to 3 percent of total Medicare payments will be held back, and hospitals will receive some portion of that money based on how well they perform on VBP metrics. Part of each hospital's performance score will be determined using measures of patient-reported experience from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, according to the study background.

"For SNHs, ensuring high performance under VBP will be particularly critical to their economic viability," according to the study background.

Paula Chatterjee, M.P.H., of the Harvard School of Public Health, Boston, and colleagues used the HCAHPS survey in 2007 and 2010 to determine performance and improvement on measures of patient-reported hospital experience among SNHs compared with non-SNHs. Their study included 3,096 U.S. hospitals, of which 769 were in the highest Disproportionate Share Hospital (DSH) index quartile and composed the SNH group.

Safety-net hospitals had lower performance than non-SNHs on nearly all measures of patient experience. The greatest differences were in overall hospital rating, for which patients in SNHs were less likely to rate the hospital a nine or 10 on a 10-point scale compared with patients in non-SNHs (63.9 percent vs. 69.5 percent). There also were sizable gaps for the proportion of patients who reported receiving discharge information (2.6 percentage point difference) and who thought they always communicated well with physicians (2.2 percentage point difference), according to the study results.

Safety-net hospitals were more likely than non-SNHs to be large hospitals that were for-profit or publicly owned, be major teaching hospitals and have fewer Medicare patients but more Medicaid and black patients than other hospitals, study results indicate.

Both groups of hospitals improved from 2007 through 2010, although the gap between SNHs and non-SNHs increased (3.8 percent in 2007 vs. 5.6 percent in 2010). SNHs also had 60 percent lower odds of meeting VBP performance benchmarks for hospital payments compared with non-SNHs, the results also indicate.

"Given that hospital payments are now tied to performance on these measures, we need renewed efforts to track performance of SNHs under VBP and may need specific quality-improvement programs targeting these organizations," the authors conclude. "Safety-net hospitals play a critical role in providing medical care to vulnerable populations, and ensuring that efforts to improve the quality of care at U.S. hospitals do not worsen existing disparities will be a key challenge to policy makers."

In an editorial, Katherine Neuhausen, M.D., of the University of California, Los Angeles, and Mitchell H. Katz, M.D., of the Los Angeles County Department of Health Services, California, write: "While it is important to improve quality at SNHs, the VBP program could push SNHs closer to the brink of bankruptcy."

"These hospitals will still be needed to care for the estimated 23 million individuals who will remain uninsured even if health care reform is fully implemented," they continue.

"The pursuit of value-based care is a worthy goal for SNHs. In its zeal to drive improvement, CMS [Centers for Medicare and Medicaid Services] should consider the precarious finances of the SNHs under health care reform. By continuing to support SNH incentive programs, CMS can provide vital resources for quality improvement and avoid a financial crisis among SNHs," the authors conclude.