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‘Safety Net’ Hospitals Ranked Low by Patients

Hospitals that provided a disproportionate amount of care to uninsured and Medicaid patients scored worse in patient satisfaction than did hospitals that bore less of a burden for uncompensated care, researchers found.

Patients at so-called safety net hospitals were less likely to rate the hospital as a 9 or 10 on a 10-point scale compared with patients at other hospitals (63.9% versus 69.5%, P<0.001), wrote Ashish Jha, MD, of Harvard Medical School in Boston, and colleagues in the Archives of Internal Medicine.

In addition, when compared against hospitals that scored lowest on the Disproportionate Share Hospital (DSH) index, safety net hospitals were 60% less likely to meet value-based purchasing baselines (OR 0.4, 95% CI 0.3 to 0.5, P<0.001).

Improving patient experience has become a priority for clinicians and policymakers, the authors explained. The Affordable Care Act has made the need to improve patient experience even more urgent as reimbursement becomes linked to hospital performance.

Value-based purchasing is a CMS program that ties Medicare and Medicaid reimbursement to that performance, based on a series of quality measures through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Hospitals that score in the top 50% of measures are rewarded for valuable service, while those that fall in the bottom 50% are penalized, with 1% to 3% of total Medicare payments held back as part of the performance evaluation.

The current study measured performance, and improvement on measures of patient-reported hospital experience, in safety net hospitals compared with non-safety net hospitals in the U.S. using data from the HCAHPS surveys from 2007 and 2010.

Safety net hospitals were defined as those in the highest quartile of the DSH index, which is a measure of the proportion of older patients receiving Supplemental Security Income and of patients receiving Medicaid.

The study included a total 3,096 hospitals, 769 of which met the criteria for safety net status. The multivariate regression estimates of HCAHPS scores by DSH Index Quartile in 2010 were:

  • Communication with physicians: 73.8% of the time in safety net hospitals versus 76% of the time in lowest-quartile hospitals (P<0.001)
  • Communication with nurses: 78.9% versus 79.5% (nonsignificant difference)
  • Communication about medications: 58.7% versus 59.9% (P=0.001)
  • Quality of nursing services: 60.2% versus 62.4% (P<0.001)
  • Presence of discharge planning: 80.2% versus 82.8% (P<0.001)
  • Pain management: 67.4% versus 69.5% (P<0.001)
  • Cleanliness of hospital: 68.8% versus 69.8% (nonsignificant difference)
  • Quietness of hospital: 56.6% versus 55.1% (P<0.001)
  • Overall quality of service: 63.9% versus 69.5% (P<0.001)

The greatest disparity between hospitals in the highest and lowest quartiles of the DSH were seen in measures of overall quality of service, whether or not patients received discharge planning information, and if a physician always communicated well with the patient. Safety net hospitals were rated significantly quieter than hospitals in the lowest quartile of the DSH index.

Only 11% of safety net hospitals scored at or above the median on the HCAHPS survey versus 26% of hospitals in the lowest DSH quartile, which translated to 60% lower odds for safety net hospitals in achieving key benchmarks for value-based purchasing.

In a comparison between the 2007 and 2010 HCAHPS survey results, there was an overall improvement for all hospitals, though there was a nonsignificant difference between how much safety net hospitals improved versus lowest quartile hospitals (3.8% difference in 2007 versus 5.6% difference in 2010, P=0.08).

The authors cited several limitations to the study, including the a priori definition of safety net hospitals according to DSH index quartiles, which is an imperfect measure. Also, they were only able to examine data over a 4-year period and it may take hospitals longer than that to improve performance. Finally, HCAHPS measures are subjective.

Although the value-based purchasing program offers incentive for hospitals to improve quality of service, safety net hospitals start at a disadvantage, wrote Katherine Neuhausen, MD, of the University of California, Los Angeles, and Mitchell Katz, MD, of the Los Angeles Country Department of Health Services, in an accompanying editorial.

“Because [safety net hospitals] take care of many patients without the ability to pay…the hospitals may not have the resources to devote to physical plant improvement or other amenities that affect patient satisfaction,” they said, adding that value-based purchasing “could push [safety net hospitals] closer to the brink of bankruptcy” and worsen the disparity between safety net hospitals and “prosperous” non-safety net hospitals.

Primary source: Archives of Internal Medicine  

Source reference: Jha AK, et al “Patient experience in safety-net hospitals: implications for improving care and value-based purchasing” Arch Intern Med 201; DOI: 10.1001/archinternmed.2012.3168.

Additional source: Archives of Internal Medicine    

Source reference: Katz MH, and Neuhausen K “Patient satisfaction and safety-net hospitals: carrots, not sticks, are a better approach” Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.3175.

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