|Medicare Hospital P4P Program May Penalize Hospitals Caring For Large Numbers Of Poor
Medicare’s pay-for-performance program ranks and
rewards hospitals, according to how well they meet certain guidelines
for clinical care.
But researchers at Duke Clinical Research Institute said
the program penalizes hospitals that care for the greatest numbers of
the poor and needy by not taking into account their greater clinical
Studies show that age, race and severity of disease can
influence which patients get certain treatments and how they fare, and
these factors vary significantly from hospital to hospital.
"That means that hospitals serving large groups of the
elderly, women, poor, uninsured or African-American patients might have
problems competing with institutions whose patients are younger,
wealthy, insured and white," said Dr. Eric Peterson, a cardiologist at
Duke and the senior author of the study. "Hospitals are simply not
starting out on the same playing field."
Under the current pay-for-performance system, hospitals
in the top 20 percent of the rankings receive financial reward; those
in the middle 60 percent receive nothing, and those at the bottom stand
to loose Medicare reimbursement money.
Currently, Medicare does not consider demographic
variables and patients’ existing health problems in figuring
Peterson and colleagues in the American Heart
Association’s Get With the Guidelines program wanted to find out
if those rankings would change if patient mix was included in the
calculations. They examined Medicare beneficiary records of 148,472
heart attack patients in 449 hospitals across the country from 2000 to
2006. They analyzed the hospitals’ process performance on eight
measures of clinical care taken from guidelines established by the
Centers for Medicare and Medicaid Services.
The measures included appropriate use of certain drugs,
like aspirin, beta-blockers, ACE inhibitors and anti-clotting
medications; and procedures, like angioplasty and counseling to support
Investigators ranked the hospitals according to crude
composite process performance scores and then grouped them according to
Medicare’s current system.
Next, they ranked the same hospitals again, but this
time taking into account the patients’ demographic variables,
their clinical characteristics and eligibility for certain procedures.
They found that the hospitals with the lowest crude
composite scores tended to be smaller, non-academic institutions that
treated a higher percentage of older, sicker and minority patients than
those in the top group.
While there was general agreement on performance between
the two ranking systems, researchers found that when taking into
account patient characteristics and treatment opportunity, 16.5
percent, or 74 of the hospitals would fall into a different financial
So why doesn’t Medicare consider patient mix in
tallying rankings? "On the surface, it may well seem to be the right
thing to do, but some feel such a move would ‘legitimize’
less-than-optimal care," said Peterson. "At the same time, not taking
these factors into consideration is like comparing apples to oranges."
Peterson said one solution might be to reward hospitals
for improvement in adherence to evidence-based treatment, rather than
rewarding a single score or ranking. Another option might involve
separately reporting adherence data for older patients, women, or
minorities. "That would surely draw more attention to any gaps in care,
and might prompt better compliance."
Address: Duke Clinical Research Institute, North Pavilion, 2400 Pratt St., Durham, NC 27705; (919) 668-8700, www.dcri.duke.edu.