'Worst' Hospitals Treat More Poor, Minority Patients

Hospitals with the highest cost but lowest quality scores care for twice as many minority and low-income patients as do hospitals with the lowest cost and the highest quality scores, according to an analysis of Medicare and hospital databases.

Harvard-based researchers, lead by Dr. Ashish K. Jha, examined quality performance data on more than 3,200 hospitals from Medicare’s Hospital Compare program and several other databases maintained by Medicare and American Hospital Association; they also examined cost information and patient demographics.

Their findings have implications as Medicare prepares to base some hospital compensation on quality, according to Dr. Jha.

The researchers stratified hospitals into quartiles, terming the highest cost/lowest quality facilities "worst" and the lowest cost/highest quality ones "best." The worst hospitals were typically smaller, public, or for-profit, and located in the South, according to the study published in the October issue of the journal Health Affairs.

The 178 worst hospitals cared for more elderly black patients than did the 122 best hospitals (15% vs. 7% respectively); the pattern was similar for elderly Hispanic patients (4% and 1% respectively).

Hospitals with the lowest quality/highest costs also served more Medicaid recipients – 22% vs. 15% for hospitals with the highest quality/lowest costs.

Dr. Jha and his associates also examined each hospital’s health outcomes for acute myocardial infarction, congestive heart failure, and pneumonia. They found that patients with acute myocardial infarction or pneumonia admitted to the worst hospitals were 7%-10% more likely to die than were their peers admitted to the best hospitals (Health Affairs 2011 [doi:10.1377/hlthaff.2011.0027]).

As policy makers seek to lower health care spending while improving quality, Dr. Jha and his associates urged caution in implementing the Medicare value-based purchasing program.

Starting in October 2012, the program will reimburse hospitals based on a series of quality performance measures including mortality rates and hospital-acquired conditions.

"While value-based purchasing is well-intended, many hospitals that disproportionately care for minorities and the poor will fare poorly," Dr. Jha said in a statement. "We will have to track closely to make sure we don’t inadvertently worsen health care disparities in the process of promoting quality and efficiency."

While the researchers point out that only 1% of Medicare reimbursement is at risk through the value-based purchasing program, "even losing a portion of that 1% may put some hospitals at risk of financial failure."

CMS officials noted that hospitals will be monitored through a variety of quality improvement programs, and minorities will be protected.

"The CMS Value-Based Purchasing program isn’t just about meeting a certain one-size-fits-all benchmark on the quality of care hospitals provide – it’s about improving the quality for every patient relative to where a hospital begins," according to an agency spokesman. "Our program takes into account patient traits such as gender, age, and health status when patients enter the hospital because we recognize that less-affluent populations may have particular needs, and we want to help hospitals treat those patients well and be successful."

The study was funded by the Commonwealth Fund. The authors reported no relevant financial conflicts of interest.

Hospitals with the highest cost but lowest quality scores care for twice as many minority and low-income patients as do hospitals with the lowest cost and the highest quality scores, according to an analysis of Medicare and hospital databases.

Harvard-based researchers, lead by Dr. Ashish K. Jha, examined quality performance data on more than 3,200 hospitals from Medicare’s Hospital Compare program and several other databases maintained by Medicare and American Hospital Association; they also examined cost information and patient demographics.

Their findings have implications as Medicare prepares to base some hospital compensation on quality, according to Dr. Jha.

The researchers stratified hospitals into quartiles, terming the highest cost/lowest quality facilities "worst" and the lowest cost/highest quality ones "best." The worst hospitals were typically smaller, public, or for-profit, and located in the South, according to the study published in the October issue of the journal Health Affairs.

The 178 worst hospitals cared for more elderly black patients than did the 122 best hospitals (15% vs. 7% respectively); the pattern was similar for elderly Hispanic patients (4% and 1% respectively).

Hospitals with the lowest quality/highest costs also served more Medicaid recipients – 22% vs. 15% for hospitals with the highest quality/lowest costs.

Dr. Jha and his associates also examined each hospital’s health outcomes for acute myocardial infarction, congestive heart failure, and pneumonia. They found that patients with acute myocardial infarction or pneumonia admitted to the worst hospitals were 7%-10% more likely to die than were their peers admitted to the best hospitals (Health Affairs 2011 [doi:10.1377/hlthaff.2011.0027]).

As policy makers seek to lower health care spending while improving quality, Dr. Jha and his associates urged caution in implementing the Medicare value-based purchasing program.

Starting in October 2012, the program will reimburse hospitals based on a series of quality performance measures including mortality rates and hospital-acquired conditions.

"While value-based purchasing is well-intended, many hospitals that disproportionately care for minorities and the poor will fare poorly," Dr. Jha said in a statement. "We will have to track closely to make sure we don’t inadvertently worsen health care disparities in the process of promoting quality and efficiency."

While the researchers point out that only 1% of Medicare reimbursement is at risk through the value-based purchasing program, "even losing a portion of that 1% may put some hospitals at risk of financial failure."

CMS officials noted that hospitals will be monitored through a variety of quality improvement programs, and minorities will be protected.

"The CMS Value-Based Purchasing program isn’t just about meeting a certain one-size-fits-all benchmark on the quality of care hospitals provide – it’s about improving the quality for every patient relative to where a hospital begins," according to an agency spokesman. "Our program takes into account patient traits such as gender, age, and health status when patients enter the hospital because we recognize that less-affluent populations may have particular needs, and we want to help hospitals treat those patients well and be successful."

The study was funded by the Commonwealth Fund. The authors reported no relevant financial conflicts of interest.

Hospitals with the highest cost but lowest quality scores care for twice as many minority and low-income patients as do hospitals with the lowest cost and the highest quality scores, according to an analysis of Medicare and hospital databases.

Harvard-based researchers, lead by Dr. Ashish K. Jha, examined quality performance data on more than 3,200 hospitals from Medicare’s Hospital Compare program and several other databases maintained by Medicare and American Hospital Association; they also examined cost information and patient demographics.

Their findings have implications as Medicare prepares to base some hospital compensation on quality, according to Dr. Jha.

The researchers stratified hospitals into quartiles, terming the highest cost/lowest quality facilities "worst" and the lowest cost/highest quality ones "best." The worst hospitals were typically smaller, public, or for-profit, and located in the South, according to the study published in the October issue of the journal Health Affairs.

The 178 worst hospitals cared for more elderly black patients than did the 122 best hospitals (15% vs. 7% respectively); the pattern was similar for elderly Hispanic patients (4% and 1% respectively).

Hospitals with the lowest quality/highest costs also served more Medicaid recipients – 22% vs. 15% for hospitals with the highest quality/lowest costs.

Dr. Jha and his associates also examined each hospital’s health outcomes for acute myocardial infarction, congestive heart failure, and pneumonia. They found that patients with acute myocardial infarction or pneumonia admitted to the worst hospitals were 7%-10% more likely to die than were their peers admitted to the best hospitals (Health Affairs 2011 [doi:10.1377/hlthaff.2011.0027]).

As policy makers seek to lower health care spending while improving quality, Dr. Jha and his associates urged caution in implementing the Medicare value-based purchasing program.

Starting in October 2012, the program will reimburse hospitals based on a series of quality performance measures including mortality rates and hospital-acquired conditions.

"While value-based purchasing is well-intended, many hospitals that disproportionately care for minorities and the poor will fare poorly," Dr. Jha said in a statement. "We will have to track closely to make sure we don’t inadvertently worsen health care disparities in the process of promoting quality and efficiency."

While the researchers point out that only 1% of Medicare reimbursement is at risk through the value-based purchasing program, "even losing a portion of that 1% may put some hospitals at risk of financial failure."

CMS officials noted that hospitals will be monitored through a variety of quality improvement programs, and minorities will be protected.

"The CMS Value-Based Purchasing program isn’t just about meeting a certain one-size-fits-all benchmark on the quality of care hospitals provide – it’s about improving the quality for every patient relative to where a hospital begins," according to an agency spokesman. "Our program takes into account patient traits such as gender, age, and health status when patients enter the hospital because we recognize that less-affluent populations may have particular needs, and we want to help hospitals treat those patients well and be successful."

The study was funded by the Commonwealth Fund. The authors reported no relevant financial conflicts of interest.