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Lowest Quality Care Goes to Poor, Minority Patients

 |  By cclark@healthleadersmedia.com  
   October 07, 2011

Harvard researchers who identified 178 hospitals that provide the lowest quality of care yet have the highest cost also found that these facilities treat a higher proportion of poor, aged, and minority patients than 122 hospitals that provide high quality and lower-cost care.

Unfortunately, the very programs designed to incentivize higher quality, specifically the federal value-based purchasing incentives set forth by the Affordable Care Act, "will have a disproportionately negative effect on these hospitals unless we figure out a way to help them improve," lead author Ashish, Jha, an associate professor of health policy at the Harvard school of Public Health said in a telephone interview.

Jha said the incentives will put a "double-squeeze on these hospitals" to come up with improvements -- a challenge that will be especially tough for them to accomplish -- or risk financial penalties. 

Jha is the lead author of a paper published this week in the October issue of Health AffairsThis month's edition is devoted to correcting disparities in healthcare delivery system.

His report found that the worst hospitals – "typically small ,public or for-profit institutions in the South – care for double the proportion (15% versus 7%) of elderly black patients as the 'best' hospitals, typically nonprofit institutions in the Northeast." 

The specific hospitals were not named. But Jha said that his "sense is that these hospitals haven't paid attention to quality, and they're also financially stressed. And when you're financially stressed, you focus more on survival than on making sure quality of care is good."

He added that what seems clear from their data is that these hospitalized patients have longer lengths of stay. "They're more expensive to take care of because they have fewer social support systems at home."

Under value-based purchasing, all hospitals automatically will receive 1% less in reimbursement for discharges starting Jan. 1, 2013. They will have a chance to earn that back based on scores they receive during a performance period that began on July 1, 2011 and ends March 31, 2012. That period will be compared with a baseline period that began July 1, 2009, and ran through March 31, 2010.

Hospitals will be scored the first year based on a formula that includes patient experience as measured by HCAHPS scores (Hospital Consumer Assessment of Healthcare Providers and Systems survey) , and 12 clinical process of care measures, such as whether a heart attack patient received a percutaneous coronary intervention within 90 minutes arrival, or whether surgical patients received an appropriate prophylactic antibiotic.

In the following years, value-based purchasing rules will deduct from federal Medicare payments another quarter percent for each of four years until the decrease reaches a maximum of  2% in 2017.

Under the Affordable Care Act, the VBP formula is expected to add, in later years, a component that measures efficiency, or how much it costs to take care of a patient. "We suspect that it will become a key part of future payment changes," Jha said, which will further punish the poorest hospitals that have high costs and poor quality.

Jha does not think the solution is to do away with value-based purchasing incentives. On the contrary, he said.

"The issue is about holding people accountable."

"What we should be focused on is two-fold. One, we should make sure that we track the impact of VBP in a thoughtful way, and measure whether this is having a positive or negative effect on disparities. But two, we also should be investing a lot more in helping these hospitals improve," he said. If the system does nothing to help them, "you will have a bunch of losers, hospitals that will fail over time, and many will shut down. But over that time, there will be thousands of patients who die needlessly," Jha said.

"We have to have accountability and we have to have pay for performance. But we also have to be aware of the real-life consequences of these policies."

The Harvard researchers used six sources to compile their list of the best and worst hospitals. They included the 2007 HospitalCompare data, the 2005 Medicare Provider Analysis and Review (MedPAR) file linked with the 2005 Medicare Beneficiary File, the American Hospital Association's annual survey of hospitals, the 2007 Medicare Impact file created by CMS, the 2007 Area Resource File with county-level poverty rates and the 2008 HCAHPS survey.

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