What P4P could mean for safety net hospitals

Are these hospitals in peril?

For the sake of her study, Rachel Werner, MD, PhD, assistant professor of medicine at the University of Pennsylvania school of medicine and researcher with the Philadelphia VA Medical Center, defined safety-net hospitals predominately by the rate of Medicaid patients seen by the facility. But she acknowledges that the term encompasses much more — in general, those hospitals that treat primarily uninsured, vulnerable patient populations.

And the thesis of her study, Comparison of Change in Quality of Care Between Safety-Net and Non-Safety-Net Hospitals, is how these hospitals would fare in a pay-for-performance environment and the unintended consequences that could result from such a system.

Werner tells Hospital Peer Review her concerns for safety-net hospitals with the advent of P4P and value-based purchasing is that these resource-poor facilities won't be able to afford to invest in quality improvement to receive incentives. That, in turn, could further erode their financial standing, adversely affecting their quality.

"Safety-net hospitals sometimes have lower quality at baseline and so for them to improve enough to get an incentive in a rank-based system may be unrealistic," she says.

One area that sets these hospitals at a disadvantage is the disparity between their patients' conditions and those requiring measurement. While safety-net hospitals deal with heart failure and heart attacks, for instance, they also contend with patients presenting "other medical problems that aren't being measured" — mental health, pregnancy, substance abuse.

If you look at CMS' Hospital Compare web site, Werner says, the measures reported on — heart attack, heart failure, and pneumonia — are areas where safety-net hospitals might lag. While one answer might be for these facilities to invest in these specific areas, they risk harming care in other areas — conditions that they treat more frequently.

The three conditions highlighted on Hospital Compare, she adds, are, of course, important ones, but for safety-net hospitals "those represent a smaller portion of that quality," not reflecting true quality across the hospital.

Vice president of the National Rural Health Association Brock Slabach agrees that those measures do not accurately capture what's going on inside a safety-net hospital, in which he includes rural and critical access facilities.

"Our rural critical access hospitals do an outstanding job providing high-quality care to their patients, but I do see what has happened in rural hospitals because of the environmental demands from all types of backgrounds. A lot of these small rural hospitals are unable to keep up with the stated demands because a lot of them have one person who is responsible for performance improvement within the facility and that's not usually the only hats they wear," he says.

What he'd like to see is "rural-relevant metrics" — "a common data set for metrics that everyone could agree on for all critical access hospitals... in the same transformative way that Hospital Compare and the Leapfrog Group and all those other data sources have done for urban hospitals."

Slabach says NRHA is assembling a workgroup next year to promote establishment of such measures. The American Hospital Association has expressed interest, he says, and his association is also working on this effort with the American Health Quality Association.

Performance improvement managers in rural hospitals "are extremely valuable," he says, and encourages them to develop good communications with their CEOs. "Using data as a tool for improvement is another thing that can be powerful, especially in a small facility because things travel so fast. Data can be a real antidote."

As far as the future of safety-net hospitals, Werner says it's difficult to predict. She's concerned the P4P movement will result in an even greater disparity between high-quality and low-quality care and questions whether resource-poor hospitals will make it in the end.

"We need to give safety-net hospitals a tool to improve quality rather than letting them figure it out," she says.