Carla K. Johnson, AP
The nation's worst hospitals treat twice the proportion of elderly black patients and poor patients than the best hospitals, and their patients are more likely to die of heart attacks and pneumonia, new research shows. Now, these hospitals, mostly in the South, may be at higher risk of financial failure, too. That's because the nation's new healthcare law punishes bad care by withholding some money, says the lead author of the study published Wednesday in the journal Health Affairs.
"These hospitals are going to have a much harder time in the new funding environment," said Dr. Ashish Jha of the Harvard School of Public Health, who led the study. "I worry they're going to get worse over time and possibly even fail. I worry that we're going to see a bunch of that happening over the next three to five years." Under the Affordable Care Act, hospitals that fail to improve will see their Medicare payments shrink by one percent starting in October 2012. That could jeopardize some hospitals already on the brink of closure, Jha said.
That unintended consequence of the health overhaul could increase health disparities for minorities, Jha said. "We have to make sure we pay attention to what the results of those policies are and be ready to change directions if they're causing harm in the marketplace," Jha said. The study doesn't name the 178 hospitals the researchers rated as "worst" because of their low quality of care and high costs. A data use agreement with Medicare prevented the researchers from identifying the hospitals publicly.
The study, funded by the Commonwealth Fund, found 122 "best" hospitals with high quality and low costs. Those best hospitals were more likely to be in the Northeast and to be non-profit.
Elderly blacks made up 15 percent of patients in the worst hospitals and about seven percent in the best hospitals. There were similar differences for people on Medicaid, the state-federal health program for the poor. Worst-hospital patients with heart attacks or pneumonia were more likely to die than similar patients at the best hospitals. Medicare chief Don Berwick called the study "valuable, but not completely new." He said the federal government is working to help all hospitals improve. "We know they can improve," even if they treat sicker or disadvantaged patients, Berwick said. "There are examples of safety net hospitals that are some of the best in the country." He cited Denver Health, which has low death rates despite treating a large share of poor patients.
The health law's so-called "value-based purchasing" rewards hospitals for their rate of improvement, not just for attaining goals, Berwick said. So hospitals that start farther behind can get rewarded for making efforts to catch up. And the law provides money for hospital improvement programs. "If I were talking to safety net hospitals, I would say, 'I know it's hard. Here's some help, and if you start (improving), you'll get rewarded for starting,'" Berwick said.
For the study, the researchers used data from six sources to determine which hospitals were worst and best. They divided the hospitals into four ranked groups for quality of care and divided them again into four ranked groups for cost.
"What can we do to take the lessons from the high-performing institutions and help the low performers improve?" Jha asked. In markets outside of health care, business closures don't so directly affect people's survival, he said, but, "here, there are tens of thousands of lives at stake." With the health law's expansion of insurance in 2014, patients may have more choice in hospitals, but most patients don't use tools like Hospital Compare to find the best ones nearby, Jha said. Hospital Compare is a government website that rates how hospitals measure up to certain standards, such as giving heart attack patients aspirin.
Nancy Foster of the American Hospital Association said the group is worried about whether the new funding formula will put safety net hospitals at financial risk, but believes all hospitals can improve. "There's no hospital in the country right now that doesn't want to do the best for the patients it serves," Foster said. "That's where research comes in and sharing results on how to improve."