If hospitals treat poorer and sicker patients, are they fated to perform worse on national quality standards? Not necessarily, shows an analysis of safety net hospitals conducted by MPA Healthcare Solutions for Modern Healthcare that found wide variation in performance within the group.
MPA's findings are significant because safety net hospitals have long argued that Medicare's ranking systems and financial penalties for hospitals disproportionately—and therefore unfairly—hurt them. Insisting that they are penalized for caring for sicker patients, these hospitals have called for better risk adjustment to level the playing field.
But MPA's analysis of 201 safety net hospitals, defined as those that treat at least 0.1% of patients who receive charity care in the U.S., showed that the quality of care at these hospitals ranges broadly. The findings from the Chicago-based healthcare analytics firm indicate that treating sicker, more vulnerable patients doesn't preclude a hospital from offering high-quality care.
The analysis, limited because it looked only at five clinical areas, examined inpatient data from the CMS' Limited Data Set from 2012 through 2014 for total hip replacements, total knee replacements, coronary artery bypass grafts, cardiac valve replacements and cholecystectomies (surgery to remove the gallbladder). It examined patient mortality, prolonged risk-adjusted length of stay, readmissions within 90 days and mortality within 90 days, using those measures to create models to gauge hospital performance.
Performance varied so widely that in one clinical area, cardiac valve replacement, 43.7% of 142 hospitals that performed the procedure were considered outliers in their performance, 10.6% were counted as “good performers,” and 33.1% were viewed as “substandard.”
Among the 174 hospitals that performed hip replacements, the analysis found 15.5% to be outliers, 4.6% were deemed good performers, and 10.9% were ranked as substandard.
Of the 149 hospitals performing knee replacements, 38.2% were outliers, 6.7% were good performers, and 31.5% were substandard. Of the 146 hospitals performing coronary artery bypass grafts, 14.4% were outliers, 5.5% were good performers, and 8.9% were substandard. For hospitals performing gallbladder removal surgery, 7.9% were outliers, 5.3% were good performers, and 2.6% were substandard.
“The goal, or the hope, coming out of this analysis is that regardless of what that patient population is that (hospitals) are serving, there's room for improvement,” said Greg Pine, CEO of MPA Healthcare Solutions.
Safety net hospitals have pushed back against CMS programs such as the Hospital Readmissions Reduction Programs, which requires Medicare to cut payments to hospitals that see excessive numbers of patients return within 30 days of discharge, for certain conditions. In August, when the CMS announced that it would penalize 2,588 hospitals in the program for fiscal 2017, America's Essential Hospitals, a membership group of safety net hospitals, was critical.
“The evidence is clear that these programs disproportionately penalize hospitals that serve disadvantaged patients and communities,” Beth Feldpush, the group's senior vice president of policy and advocacy, said in a statement at the time.
It's easy for safety net hospitals that perform poorly to blame results on the challenges they face due to their patient populations that other hospitals do not, Pine said, but MPA's analysis helps debunk that claim.
He compared the idea to that of running a 4-minute mile, once considered an impossible achievement until Roger Bannister broke that barrier in 1954. Since then, hundreds of others have followed suit.
“It's not that there's a one-size-fits-all, easy solution that all of these places can do,” Pine said. But if some safety net hospitals perform better than others, lower-performing ones can look to them to see what is working. “Ultimately, there's something that's explaining that difference in terms of the quality of care,” Pine said.