Safety net hospitals face socio-economic disadvantages

For the health policy team at Henry Ford Hospital, understanding the economic and demographic makeup of the local community is essential. Many of the patients who visit the 751-bed safety net hospital in Detroit come from neighborhoods that have specific challenges, which hospital officials say could negatively affect patient-care outcomes.

Among the challenges are “low household income, reduced access to grocery stores, reduced access to a neighborhood pharmacy, and greater dispersion of people because you have abandoned houses and vacant lots,” said David Nerenz, director of the Center for Health Policy and Health Services Research at the Henry Ford Health System.

The lack of reliable transportation makes it difficult for patients to get to follow-up appointments or to pick up medications. “So, you have people who are more likely to be reliant on public transportation, but then they are only able to get by with the frequency the buses show up,” he adds.

According to U.S. Census Bureau data, about 38% of the population of Detroit had an income that fell below the poverty level between 2008 and 2012, more than double the average for the state as a whole. Nearly 83% of the population is black.

These are all aspects, Nerenz said, that potentially feed into the problem of patients returning to the hospital within 30 days of being discharged, an issue for which U.S. hospitals are now penalized under the CMS' Hospital Readmissions Reduction Program, a part of the Patient Protection and Affordable Care Act.

The CMS calculates each hospital's readmission performance over a three-year period, for conditions such as acute myocardial infarction, heart failure and pneumonia. If a hospital has an excess readmission ratio that is worse than the national average, the hospital is subject to a penalty of up to 2%. The methodology takes into account individual factors, such as the presence of co-morbidities that disproportionately affect certain patient groups. But health policy advocates are pointing to a growing body of research that suggests the socio-economic conditions of the overall community, specifically unemployment, racial composition and the amount of uninsured people, should also be included to more fairly apply the penalties and rewards, and prevent hospitals with the highest need from being unfairly penalized for factors beyond their control.

“As we link rewards to penalties, it's all the more important to understand where these problems come from,” Nerenz said. “Perhaps the effective measures are not in the hospital at all, but in some other aspect of community care.”

America's safety net hospitals, because they provide care for disproportionately higher numbers of patients in these challenging demographics, may be vulnerable to disproportionately higher penalties under the current methodology for penalizing readmissions.

In response to these concerns, more researchers have been delving into whether the socio-economic aspects of the community really do matter. A new study from the research and data firm Truven Health Analytics is among the latest to tackle the issue, by attempting to quantify exactly how much certain demographic factors could impact readmission rates.

Using CMS data, which included more than 2,225 hospitals that had been penalized as of October 2013, researchers evaluated seven factors on the community need index, such as poverty among the elderly, the number of people without a high school education, unemployment rates and language barriers. The report found race and unemployment were particularly strong predictors of higher readmission rates. About 18% of a community's readmissions could be attributed to unemployment, the analysis found. So, if about a fifth of the people in a community are unemployed, for example, a hospital could potentially attribute about 3.6% of their readmissions to people not having jobs, explained David Foster, lead scientist for Truven's Center for Healthcare Analytics.

The study also found about 6% of readmissions could be attributed to poverty among the elderly. In terms of race, the chances of a black patient being readmitted were almost 15% higher than they were for a white person who was otherwise similar.

“This is a disparity issue that has been going on for a long, long time in American medicine, and it's not surprising to see it again here,” said Foster, who said the burden of “stubborn societal issues” can't be solved by a hospital alone.

Each year Truven releases its 100 Top Hospitals list, which recognizes high-performing facilities based on 14 performance measures, including reducing mortality and inpatient complications; improving patient safety; reducing average patient stay and expenses; profitability; patient satisfaction; adherence to clinical standards of care; and post-discharge mortality and readmission rates for acute myocardial infarction (heart attack), heart failure and pneumonia. When Truven compared the top performers for 2014 on readmission penalties in a subanalysis of the recent study, while they found no significant differences in the measure among top-rated facilities, those in areas that had high community-need index ratings still fared poorly on readmissions.

“If you're talking about intractable societal problems like that, there are no easy solutions,” Foster said. “Hospitals should not be getting penalized unfairly. That's just wrong.”

America's Essential Hospitals, a 220-member national association that advocates for the nation's safety net hospitals and health systems, provides on its website links to more than 15 studies looking at specific socio-economic data related to health outcomes, such as surgical mortality, cancer survival and blindness.

Among the studies is one published in May in the journal Health Affairs, which looked specifically at the effect of community socio-economic status on readmission rates at Henry Ford. The study found patients living in high-poverty neighborhoods of the city were 24% more likely to be readmitted to the hospital. Being male and unmarried was also associated with higher readmission rates, but the study did not address why these two factors were associated.

Advocates from America's Essential Hospitals say the Truven and Health Affairs analyses are consistent with research they have been monitoring over the past few years.

“The scientific literature is there,” said Beth Feldpush, senior vice president of policy and advocacy at America's Essential Hospitals. More of the vulnerable hospitals are being penalized when you look at the broad cross-section of U.S. hospitals, she said, and factors outside of the hospitals' control should be taken into account.

“We don't believe there is fairness in the measurement system right now,” Feldpush said.

The CMS said it is committed to ensuring that hospitals serving disadvantaged populations are not unfairly penalized, but it has found that safety net hospitals can and do perform well on readmissions measures. Association between certain socio-demographic factors and health outcomes can be due, in part, to differences in the quality of the healthcare received, the CMS said. “Adjustment for these factors could confound the results,” the agency said in a statement.

Though it acknowledges the complexities of the issue, the CMS contends that hospitals can influence some of the socio-economic factors in their communities. “The scope of activities that fall within a hospital's control is wider than it may seem, giving hospitals a range of opportunity to influence readmission rates in their community.”

In 2011, there were approximately 3.3 million adult, 30-day, all-cause hospital readmissions in the U.S., and they were associated with about $41.3 billion in hospital costs, according to recent data from the Agency for Healthcare Research and Quality. Medicare patients had the largest share of total readmissions (55.9%), and Medicaid had the second-largest (20.6%).

But progress is being made in driving down the rates, according to an HHS report released in May, which found the rate for Medicare beneficiaries continued a downward trend, dropping to 17.5% through the end of 2013.

Despite the progress, even hospitals that have seen significant improvements in their readmission rates remain concerned about the socio-demographic impact. “When you penalize people, they will make an attempt (to make improvements) … but that attempt can go only so far,” said Dr. Paryus Patel, chief medical officer at Centinela Hospital Medical Center in Inglewood, Calif., which was recognized in March as one of Truven's 100 Top Hospitals in the large community hospitals category.

Like Henry Ford in Detroit, Centinela, a 369-bed facility of the Prime Healthcare System, faces specific local challenges. The hospital is in a community where one-fifth of the population (20.1%) fell below the federal poverty line between 2008 and 2012. Some large portions of the population are black or Hispanic, and patients often present with various co-morbidities, Patel said.

During federal fiscal 2013, the first year that the CMS' 30-day readmissions penalties were implemented, the hospital saw a 1% penalty. But the facility saw significant improvement the second year (dropping to a penalty of 0.59%), which they attribute, in part, to the implementation of a post-

discharge phone call program to remind patients about follow-up appointments. Another factor was an affiliation with a local pharmacy that offers delivery services six days a week within a 15-mile radius to help patients without reliable transportation. Despite the success, Patel said, getting to the ideal—suffering no penalty—is not likely to happen.

“There is no way a hospital can control all the variables,” he said. “We've made a small dent, but we're not capable of changing the whole picture.”

That sentiment was echoed by Henry Ford's Nerenz, who said his hospital has initiated partnerships with community healthcare workers who have special training to help local patients with high levels of need, and language programs to help those for whom English is not a first language to improve medication adherence. The hospital received a 1% penalty in fiscal 2013, and improved to an 0.80% penalty for the current year.

“That is money taken away,” Nerenz said, noting that a penalty can equate to hundreds of thousands of dollars.

And the real irony, said Foster of Truven, is that it adds an additional challenge to hospitals that are already strapped.

“Now they have less ability to deal with the problem than they did before,” he said.

Follow Sabriya Rice on Twitter: @MHsrice