Underfunding, Understaffing Hobble Outcomes at Safety Net Hospitals

Even after controlling for severity of illness and socio-economic status, safety net hospitals still had slightly worse outcomes and significantly higher costs than other hospitals, according to a JAMA Surgery report.

Complex elective surgeries at understaffed, underfunded safety net hospitals have slightly worse outcomes but significantly higher costs than at more-specialized hospitals with a more selective patient mix, according to a study published this month in JAMA Surgery.

Using federal Hospital Compare data from 2009 to 2012, researchers from the University of Cincinnati Medical Center examined more than 12.6 million patient encounters at 231 hospitals with high, medium, and low safety net "burdens."

The hospitals were compared on postoperative mortality, 30-day readmission, and total direct cost of care. In seven of nine complex elective procedures, the "high-burden hospitals" had the highest proportion of emergent cases and the longest lengths of stay.

After adjusting for patient characteristics and hospital volume, the HBHs still had higher odds of mortality, readmissions, and highest costs of care.  An analysis of Hospital Compare data also found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency, the JAMA report said.

Study lead author Richard S. Hoehn, MD, a general surgery resident at University of Cincinnati Medical Center, says the researchers went into the study assuming that there were differences in outcomes at safety net hospitals when compared with conventional hospitals, but they wanted to determine if the patient mix was driving these differences or the hospitals themselves.

"We found that after controlling for severity of illness and socio-economic status these safety net hospitals still had slightly worse outcomes, but they had significantly higher costs for seven of the nine procedures we examined," Hoehn says.

"That this persists after adjustment tells us two things. One, there are probably some inherent inefficiencies of the systems' inability to be a jack-of-all-trades in an efficient cost-effective manner. But there are also a lot of nuances with how sick a patient really is, what their resources are, [and] their ability to handle a major surgery that we just simply can't capture with that kind of risk adjustment."

Hoehn says safety net hospitals start with an immediate disadvantage of being understaffed and underfunded, when compared with conventional or more-specialized hospitals that have the resources to perform cost-effective surgeries and invest in money-saving enhanced recover pathways and patient education initiatives.

"Safety net hospitals have to treat anyone who comes through the door and they are not in a financial position to invest in quality improvement initiatives such as those," Hoehn says. "When we analyzed the Medicare data, we found that they have slower, less efficient emergency rooms. In other studies we are doing now, we are finding they have inferior staffing, lower numbers of physicians and nurses per bed, things like that that certainly contribute to their inability to be cost effective."

Hoehn concedes that the study's findings are hardly counter-intuitive. "Anybody who's ever spent time in a safety net hospital knows that is the case," he says. "While it is very intuitive, it doesn't make sense that the people who make policy haven't taken this into consideration. All these programs assign a one-size-fits-all metric or bundled payment for procedures that doesn't take into consideration the handicaps that are encountered at institutions designed to take care of the safety net population."

Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, says the study raises good questions about the role of safety net hospitals, but he questioned the data upon which the findings are based.

"The administratively derived Medicare Hospital Compare metrics are not clinically validated in many cases, and CMS no longer captures Surgical Care Improvement Project metrics because the agency found those measures fail to reflect the actual care delivered," Siegel wrote in an email exchange with HealthLeaders Media.

"Also, the study examines surgical complications from a set of AHRQ patient safety indicators never intended for this type of comparison," Siegel said. "Our hospitals' analysis has shown that PSIs, which are based on billing and disconnected from the actual care delivered, greatly disadvantage academic medical centers due to the severe acuity of their patients."

Siegel said his "larger concern" is whether or not the study "reliably adjusted for socioeconomic status (SES), when even CMS cannot risk adjust for SES because the determining variables have yet to be defined."

Hoehn agreed that trying to factor-out socio-economic status is difficult, "especially with 30,000-foot level data."

"You have someone who, whether they are on Medicaid or no insurance, their primary care and their overall health status is probably inferior to someone with commercial insurance and better access to care," he says. "Even if they have government insurance that reimburses more poorly at a lower level than private insurance, the hospitals seeing these patients who are sicker are going to be reimbursed less for seeing the sicker patients. So there is no way to account for that."

Hoehn says he believes the report provides more evidence that corrective measures are needed to level the field for safety net hospitals.

"It is important to do two things. First, adequately risk-adjust reimbursement policies so we are not applying the one-size-fits-all reimbursements or outcome penalty to every hospital in the country," he says.

"The other thing is to investigate for these safety net providers how to invest money wisely into improving their systems and elevating their performance to the level of more financially solvent institutions. There is plenty of research that shows that financial penalties for hospitals who are underperforming only exacerbates their position. If you could strategically invest in quality improvement initiatives for these hospitals that take care of these sick patients you might have better success improving outcomes."

As for individual safety net hospitals, Hoehn says being proactive is difficult on a limited budget.

"If this were a purely capitalistic market I would say these hospitals need to get rid of expensive cumbersome service lines that are dragging down their bottom line, but that is not possible because of the mission of safety net hospitals," he says. "Likely, it might be finding the most cost-effective, biggest-bang-for-the-buck initiatives you can invest in with pre- and post-operative care for these patients."