Study highlights huge disparities in care
BETHESDA, MD – The 178 “worst” hospitals in the United States care for more than twice the proportion of elderly minority and poor patients as the nation’s 122 “best” hospitals, where costs are lowest and quality highest.
A new study by researchers at the Harvard School of Public Health shows that patients at the worst hospitals – the lowest-quality, highest-cost 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.
The study’s lead author Ashish K. Jha and his Harvard colleagues examined the associations among quality, costs and types of patients served in approximately 3,200 hospitals nationwide. They identified 122 “best” hospitals 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).
The authors found that elderly black people constituted nearly 15 percent of the patients in the worst hospitals compared to 6.8 percent in the best hospitals. Patients with heart attack or pneumonia who were admitted to low-cost, low-quality hospitals or high-cost, low-quality hospitals were more likely to die (12-19 percent and 7-10 percent, respectively) than similar patients admitted to the best hospitals.
The worst hospitals were smaller than the best hospitals, 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 region of the United States and were often equipped with cardiac intensive care units. The best hospitals also treated a higher proportion of Medicare patients than the worst hospitals.
Jha said the new Medicare value-based purchasing system scheduled to take full effect in 2013 had implications for patients served by the worst hospitals. Under the VBP system, 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.
“There are a lot of already disadvantaged hospitals that will not do well in this environment, and there will be significant consequences for their patients,” Jha said. “While value-based purchasing is well-intended, many hospitals that disproportionately care for minorities and the poor will fare poorly because they will have to improve quality to avoid financial penalties in an environment where overall payment rates are declining.”
Maulik Joshi, senior vice president of research for the American Hospital Association, said hospitals needed effective tools and strategies to eliminate disparities in care revealed by the study.
“We need to address the many factors that impact community health, such as access to preventive and follow-up care, and work with all stakeholders to ensure improved care for patients and communities,” he said.
Donald Berwick, MD, administrator of the Centers for Medicare & Medicaid Services, said the study was valuable but not completely new.
He said the Medicare VBP program rewards hospitals for their rate of improvement, not simply for attaining quality benchmarks.
“If I were talking to safety net hospitals, I would say, ‘I know it's hard. Here's some help, and if you start (improving), you'll get rewarded for starting,’” Berwick told the Associated Press.