On nearly every measure of the Hospital Consumer Assessment of Health Plans Survey patient experience questionnaire, 769 hospitals that treat the largest share of low-income patients scored 5.6 percentage points lower than their 2,327 non-safety net counterparts, according to a review of survey responses between 2007 and 2010.
"What we found was that these safety net hospitals generally do worse on this measure, and I don't think we knew that before we did our work," says Ashish Jha, MD, corresponding author for the study published in Tuesday's Archives of Internal Medicine.
The finding is critically important. A key section of the Patient Protection and Affordable Care Act mandates that those survey response scores now influence how much hospitals are paid for Medicare patient care starting Oct. 1.
Past survey scores over a three-year period influence a significant chunk of each hospital's value-based purchasing incentive payment. The maximum penalty as of Oct. 1 is 1% of a hospital's Medicare DRG payments but rises to 2% by 2017.
If large numbers of a hospital's patients say their doctors and nurses "always" answered their questions, that their pain was "always" well controlled, and said that their room and bathroom were "always" clean, the survey responses influence just under one-third of that 1% to 2%.
But scores at safety net hospitals, which are more likely to be old, look unclean, or have a more run-down appearance, could be influenced by factors that are beyond the hospital's immediate control.
In their article, Jha, associate professor for health policy and management at Harvard School of Public Health, and colleague Paula Chatterjee postulated two explanations for the disparity in how patients answered the HCAHPS survey.
"One is that patients (in safety net hospitals) have very different expectations (than do patients in other hospitals). And the alternative is that these hospitals have not done as good of a job focusing on these patient issues," he says.
"You can tell a story for either one. But my personal feeling is that these hospitals have not done as good of a job focusing on the patient experience aspects of healthcare. And it's not totally surprising. They're very financially stressed. The reimbursement they get from a large chunk of their patient population is so low they're chronically underfunded. So it's not totally surprising."
In their paper, Jha and Chatterjee found that the greatest differences were seen in how patients responded to the question about overall hospital rating. Only 63.9% of safety net hospital patients gave the hospital the highest score of 9 or 10 while 69.5% of patients at non-safety net hospitals gave their caregivers the high score.
The one sole exception was that safety net hospitals in the southern part of the United States gave their hospitals scores as high as patients in their non-safety net counterparts.
Jha's report mentioned other possible explanations for the variation between safety net and non-safety net hospital responses. Safety net hospitals had substantially fewer nurses per 1,000 patient days than non-safety net hospitals, and had more patients covered by Medicaid and fewer patients covered by Medicare, and more black patients, than their non-safety net counterparts.
"Hospitals in the highest disproportionate share hospital index quartile share (a measure of federal subsidy for hospitals that treat the poor) had about 40% lower margins...than hospitals in the lowest DSH index quartile," they wrote.
During debates about the value-based purchasing formula, safety net hospitals complained during federally-sponsored open door forums that their patients were sicker and thus less likely to give favorable responses to the HCAHPS survey.
They argued that they were being placed at a disadvantage and deserved an adjustment to take into consideration poverty, language barriers and cultural issues specific to inner city or more dilapidated hospitals.
Their request for an adjustment was not granted because, argued officials for the Centers for Medicare & Medicaid Services, patients at some safety net hospitals working under similar adverse conditions do respond most positively to their HCAHPS surveys. If some hospitals can do it, then all could, they reasoned.
Jha disagrees that there should be any adjustment.
"I think that ultimately, all patients deserve good patient-centered care, so this is not an issue for adjustment. This is an issue for developing a strategy to get these hospitals to improve," he says.
In an accompanying editorial, Mitchell Katz, MD, director of the Los Angeles Department of Health Services and Katherine Neuhausen, MD, a family medicine physician at UCLA, also suggested the new payment penalties in the HCAHPS survey puts safety net hospitals at an unfair disadvantage, and could even "push SNHs closer to the brink of bankruptcy."
They urged the Centers for Medicare & Medicaid Services and state Medicaid agencies to instead design incentive programs that reward safety net hospitals for improving patient experience and quality "before implementing penalties."
"Because safety net hospitals take care of many patients without the ability to pay, some with conditions that require extra resources (e.g. social work, behavioral health care), the hospitals may not have the resources to devote to physical plant improvements or other amenities that affect patient satisfaction," they wrote.
"Long waits due to the heavy demand for services that are not available anywhere else for uninsured or Medicaid patients may result in patients feeling dissatisfied with their care."
Additionally, they questioned whether good scores on patient experience surveys indicate the patients received good quality of care. "In a recent study, higher patient satisfaction was associated with higher expenditures for overall healthcare and prescription drugs as well as increased mortality," they wrote, suggesting that such incentive systems "could have unintended consequences on healthcare utilization and outcomes."
Beth Feldpush, vice president for advocacy and policy for the National Association of Public Hospitals and Health Systems, also has concerns that safety net hospitals are unfairly disadvantaged by the incentive payment penalties.
While her organization supports the HCAHPS tool and is working hard to help its member hospitals improve their scores, "we need to make sure the measures are fair and don't penalize any subset of hospitals based on some subset or characteristic these hospitals have in common.
Now that hospitals have six years of experience with the HCAHPS survey, safety net hospitals' concerns are being validated with research papers like this one, she says.
She gave three examples of how HCAHPS answers may be biased against safety net hospitals.
First, she says, "the methodology does not adjust for whether a patient comes in for emergency care, or requires other specialized services that may have required a transfer to the large regional safety net hospital from a smaller community hospital," she says. "And if you have a patient who was transferred, they don't necessarily have that personal or community connection, and may be less likely to rate their care highly.
Second, she says, safety net hospitals treat large numbers of patients with behavioral, mental or substance abuse issues. And while the HCAHPS survey is not sent to patients with those problems listed as a primary diagnosis, the survey is sent to patients who have those issues as a secondary diagnosis.
"That may not be the primary reason why the patient is hospitalized, she says, "but it is still one of the health challenges the individual is facing and it could color their response."
Third, she says, "there is some work, although not yet published in a peer reviewed journal, that patients that are sicker rate their care experience lower, regardless of other characteristics. It sort of makes a lot of sense intuitively. Well we know safety net hospitals care for more intense patient case mix than other hospitals."
Feldpush summed up that it's unclear whether any of these three factors influence HCAHPS responses, but with more survey experience, some of these impacts should be investigated, she says.
"We don't know if that's the case, but these are the types of questions that, now that we've been using the HCAHPS for about six years, we need to go back and ask."