Medicare used to give these hospitals extra payments for taking care of poor people. But under health care reform, they'll get less of that funding and more for how they perform on a variety of measurements, including how patients rate them.
"Our results suggest that safety-net hospitals are struggling on this important metric. As a result, safety-net hospitals are likely to get penalized under the new payment scheme," said Paula Chatterjee, a medical student at Harvard School of Public Health. "Given that safety-net hospitals are already financially stretched, even small losses can be potentially devastating for these hospitals."
At issue are hospitals that serve poor people, often including those who don't have health insurance. According to the study, they tend to be sicker than other patients and have less trust in the health care system.
Under health care reform, the federal government punishes hospitals that perform poorly on a variety of measures by not giving them some Medicare payments.
The researchers studied 3,096 hospitals and examined answers that patients gave to surveys about their experiences at the hospitals. The safety-net hospitals -- 769 of the total -- were slightly less likely than other hospitals to be in urban areas (many are in rural parts of the country), much more likely to serve Medicaid patients and more likely to have fewer nurses per patient.
The safety-net hospitals had the lowest overall rating among patients and ranked a bit lower in the patient perception of things such as communication with medical staff and management of their condition.
"Safety-net hospitals are a critical part of our health care system. They provide care to everyone, irrespective of the patient's ability to pay. The new payment scheme, which ties part of the hospital payments to how those hospitals do on patient-reported scores, is laudable in its goals," Chatterjee said. "Our paper says that under the new scheme, safety-net hospitals are likely to do poorly. We need new strategies to help these hospitals improve."
What could be done? Chatterjee said Medicare should work with hospitals to help them do a better job of caring for patients. "Given the challenges of caring for a relatively poor population and the low reimbursement rates, we suspect that many hospitals have not been able to focus on optimizing patient experience," she said. "It's time to help these hospitals do so."
In a commentary, Dr. Katherine Neuhausen, a physician at the University of California, Los Angeles, and Dr. Mitchell Katz, director of the Los Angeles County Department of Health Services, wrote that the federal government should try to help the hospitals instead of adding pressure. One way to do that, they write, is to give more money to the hospitals that perform well instead of penalizing those that don't.
The study appeared online July 16 in the Archives of Internal Medicine.
More information
To compare the quality of hospitals, try the federal government's Hospital Compare website.
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