Blog | Friday, October 7, 2011

QD: News Every Day--'Worst' hospitals treat twice as many minority, poor patients

Hospitals that provide the lowest quality care at the highest cost care for more than twice the proportion of elderly minority and poor patients as the nation's best performers, researchers found. And patients at the "worst" institutions are more likely than patients elsewhere to die of certain conditions, such as heart attacks and pneumonia.

These hospitals and their patients may be the ones most at risk under new Medicare payment arrangements that could cut payments to hospitals that fail to meet quality metrics, reported researchers from the Harvard School of Public Health.

The researchers examined how quality, costs and patients served correlated among 3,200 hospitals nationwide. They then identified 122 "best" hospitals, those that were in the highest quartile of quality and lowest quartile of risk-adjusted costs, and 178 "worst" hospitals, those in the lowest quartile of quality and the highest quartile of costs.

Hospital quality and performance data were taken from six different data sets created by the government, nongovernment agencies and medical associations. Results appeared in Health Affairs.

The worst hospitals were smaller, were usually for-profit or public, and tended to be located in the South. The best hospitals were typically nonprofit institutions located in the Northeast, were major teaching hospitals and were in urban areas. They were more likely to have cardiac intensive care units and have higher nurse-to-patient ratios. The best hospitals also treated a higher proportion of Medicare patients than the worst hospitals.

Elderly black patients were nearly 15% of the patients in the worst hospitals, compared to 6.8% in the best hospitals. Patients with myocardial infarction or pneumonia who were admitted to low-cost, low-quality hospitals or high-cost, low-quality hospitals were more likely to die (12% to 19% and 7% to 10%, respectively) than similar patients admitted to the best hospitals. There were no meaningful difference in outcomes at the worst compared to the best hospitals among patients admitted with congestive heart failure, and the results across all three conditions were similar after adjustment for hospital characteristics.

The study authors also warned about the implications for poorer and minority patients served by the worst hospitals of new Medicare payment arrangements scheduled to take effect in 2013. Then, the federal government will grant higher payments to high-quality, efficient hospitals that meet specific quality metrics and will cut payments to institutions that fail to meet them or to improve.

In the future, CMS will likely pay closer attention to "efficiency," the authors wrote, and even if such metrics are not formally part of the system, reduced future payments to hospitals will force the issue. And private payers will follow CMS' lead by enacting tiering systems to steer patients away from high-cost, low-quality hospitals.

"The institutions that perform worse on both quality and cost metrics care for greater numbers of elderly black and Medicaid patients, and they would probably have to improve on both of these metrics to achieve parity with other hospitals and avoid financial penalties," the authors wrote.

"The 1% of Medicare reimbursement at risk through the value-based purchasing program may appear modest. However, given that many hospitals are running at zero or even negative margins, even losing a portion of that 1% may put some hospitals at risk of financial failure. Given that low-quality hospitals often have lower margins than average, the impact on them could be particularly striking."