Pay-for-performance schemes could hurt hospitals in poor neighborhoods
by Brendon Nafziger
, DOTmed News Associate Editor | June 30, 2010
Pay for performance measures
may rob from the poor hospitals
and give to the rich
An upcoming Medicare scheme that rewards hospitals that hit performance benchmarks might turn the government into a "reverse Robin Hood," according to a new study, as hospitals in poor regions with less educated inhabitants might lose out on funds they desperately need to their more advantageously situated counterparts.
The Centers for Medicare and Medicaid Services looks to roll out a plan in the next two to three years that rewards hospitals by how well they meet certain performance measures, in an effort to encourage better health care. But some investigators think the program falsely assumes all hospitals have the same financial and personnel resources to rapidly meet performance benchmarks. And the program could bring with it an unintended consequence: hurting hospitals in low-income areas already struggling to operate.
The idea for the research occurred to Dr. Jan Blustein, a professor of health policy and medicine at New York University's Wagner school of public service and lead author of the study, when she was consulting with hospitals in low-income, predominantly minority areas.
"It struck me that they didn't have what they needed in a lot of ways," Blustein told DOTmed News. "Asking them to perform at the level of a hospital I would be admitted to if I were sick is a bit silly."
In the study, published online Tuesday in open-access journal PLoS Medicine, Blustein and her colleagues analyzed 2,705 hospitals from 2004 to 2007 on Hospital Quality Alliances measures voluntarily reported to Medicare.
For the study, the researchers looked at HQA metrics for heart attacks and heart failure, such as whether patients having a heart attack got aspirin in the emergency room, or whether those with heart failure got the proper assessment of heart function. The researchers chose these measures because they depended on the hospital staff, and not on patient demographic factors, Blustein said.
The researchers then gave hospitals composite mean scores, out of 100, for each condition, to assess how well they did.
The researchers also modeled how pay-for-performance schemes would work in practice by assigning another set of scores based on a proposal described by CMS in a 2007 report to the U.S. Congress. In this, they graded for their absolute performance, or attainment, and also for how much they improved over the previous reporting year. Both scores were out of 10, with the hospital getting whichever of the two numbers was greater.
The researchers found hospitals in counties with longstanding poverty, the fewest college and high school graduates, and the most unemployment tended to fare the worst on these measures. For instance, hospitals located in areas blighted by decades of serious poverty -- with over a fifth of the population considered poor -- earned on average nearly three points less for mean composite heart attack performance measures in 2007, according to the study.