Quality of Care at Safety-Net Hospitals and the Impact on Pay-for-Performance Reimbursement

Abstract

Pay-for-performance reimbursement ties hospital payments to standardized quality of care metrics. The impact of pay-for-performance reimbursement models on safety-net hospitals which care primarily for uninsured or underinsured patients remains poorly defined. This study evaluates how standardized quality of care metrics vary by a hospital’s safety-net status. This will help us understand the potential impact that pay-for-performance reimbursement could have on funding of safety-net hospitals. We identified 1,705,704 bladder, breast, cervix, colon, endometrium, gastric, lung, ovary, or rectum cancer patients treated at 1,344 hospitals diagnosed between 2004 and 2015 within the National Cancer Database. Safety-net burden was defined for each hospital as the percentage of uninsured or Medicaid patients cared for by that hospital. Hospitals were grouped into low-, medium-, and high-burden hospitals. We evaluated the impact of safety-net burden on concordance with 20 standardized quality of care measures, adjusting for differences in patient age, gender, stage at diagnosis, and comorbidity. Patients seen at high-burden hospitals were more likely to be young, male, black, Hispanic, and reside in low-income and low-educated regions. High-burden hospitals had lower adherence to 12 of 20 quality measures compared to low-burden hospitals (all p<0.001). Among the 350 high-burden hospitals the quality of care concordance rates were lowest for those caring for the highest fraction of uninsured or Medicaid patients, minority serving hospitals, and those caring for less educated patients (all p<0.001). Cancer care at safety-net hospitals was associated with lower concordance to standardized quality of care measures. Under a pay-for-performance reimbursement model these lower quality of care scores could decrease payments to safety-net hospitals, potentially increasing health disparities for at-risk cancer patients.Abstract 1138; Table 1Quality MeasureAdjusted quality metric concordance ratep-valueLow-burdenHigh-burdenPercent differenceBladderLymph node removal57.2%54.8%-2.4%0.007Surgery87.6%87.7%0.1%0.26Chemotherapy63.3%61.3%-2.1%<.001BreastRadiation after breast conserving surgery92.0%88.6%-3.4%<.001Chemotherapy88.7%85.2%-3.5%<.001Hormone therapy90.2%86.8%-3.5%<.001Radiation after mastectomy80.8%76.2%-4.7%<.001CervixBrachytherapy65.5%65.3%-0.3%0.97Radiation timing78.5%75.8%-2.7%0.02Chemotherapy and radiation85.6%85.2%-0.4%0.92ColonChemotherapy89.1%85.0%-4.1%<.001Lymph node removal86.0%83.0%-3.0%<.001EndometriumChemotherapy and radiation76.1%76.2%0.1%0.09Surgery70.6%59.5%-11.1%<.001GastricLymph node removal48.4%47.9%-0.5%0.95Non-Small Cell LungLymph node removal38.7%36.7%-2.0%0.11Chemotherapy97.7%97.3%-0.4%0.12Surgery89.8%90.6%0.8%0.02OvarySurgery68.7%64.4%-4.2%<.001RectumChemotherapy and radiation81.5%79.3%-2.2%0.003 Open table in a new tab