Safety-net hospitals, which typically care for low-income patients, performed more poorly than other hospitals on nearly every measure of patient experience, according to a study.

That issue could have financial consequences with a push to connect Medicare payments to performance, researchers reported July 16 on the website of the Archives of Internal Medicine.

Value-based purchasing, a program run by the Centers for Medicare and Medicaid Services, ties part of each hospital’s payments to its performance on a set of quality measures beginning in October. Under the program, about 1% to 3% of total Medicare payments will be held back, and hospitals will receive some portion of that money based on how well they perform on VBP metrics.

Part of each hospital’s performance score will be determined using measures of patient-reported experience from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, the researchers noted. For safety-net hospitals, "ensuring high performance under VBP will be particularly critical to their economic viability," they wrote.

Paula Chatterjee, MPH, of the Harvard School of Public Health in Boston, and colleagues used the HCAHPS survey in 2007 and 2010 to determine performance and improvement on measures of patient-reported hospital experience among safety-net hospitals (SNHs) compared with non-SNHs. Their study included 3,096 U.S. hospitals, of which 769 were in the highest Disproportionate Share Hospital index quartile and composed the SNH group.

SNHs had lower performance than non-SNHs on nearly all measures of patient experience. The greatest differences were in overall hospital rating, in which patients in SNHs were less likely to rate the hospital a nine or 10 on a 10-point scale compared with patients in non-SNHs (63.9% vs. 69.5%).

The researchers also found a difference of 2.6 percentage points between SNHs and other hospitals in the number of patients who reported receiving discharge information, and a difference of 2.2 percentage points in the number of patients who thought they always communicated well with physicians.

Safety-net hospitals were more likely than non-SNHs to be large hospitals that were for-profit or publicly owned, be major teaching hospitals and have fewer Medicare patients but more Medicaid and black patients than other hospitals, according to the study data.

Both groups of hospitals improved in overall rating by patients from 2007 through 2010, although the gap between SNHs and non-SNHs increased. SNHs also had 60% lower odds of meeting VBP performance benchmarks for hospital payments compared with other hospitals, the results indicated.

"Given that hospital payments are now tied to performance on these measures, we need renewed efforts to track performance of SNHs under VBP and may need specific quality-improvement programs targeting these organizations," the authors wrote. "Safety-net hospitals play a critical role in providing medical care to vulnerable populations, and ensuring that efforts to improve the quality of care at U.S. hospitals do not worsen existing disparities will be a key challenge to policymakers."

In an editorial, Katherine Neuhausen, MD, of the University of California, Los Angeles, and Mitchell H. Katz, MD, of the Los Angeles County Department of Health Services, wrote: "While it is important to improve quality at SNHs, the VBP program could push SNHs closer to the brink of bankruptcy. These hospitals will still be needed to care for the estimated 23 million individuals who will remain uninsured even if healthcare reform is fully implemented.

"The pursuit of value-based care is a worthy goal for SNHs. In its zeal to drive improvement, CMS should consider the previous finances of the SNHs under healthcare reform. By continuing to support SNH incentive programs, CMS can provide vital resources for quality improvement and avoid a financial crisis among SNHs."

To read the study, visit http://bit.ly/OJXi9w. For more information on the VBP program, visit http://go.cms.gov/O3hntR.