Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients

doi:10.1016/j.ahj.2007.10.043

American Heart Journal

Volume 155, Issue 3, March 2008, Pages 571-576

https://doi.org/10.1016/j.ahj.2007.10.043 Get rights and content

Objectives

The purpose of this study was to determine whether pay-for-performance (PFP) increases existing racial care disparities.

Background

Medicare's PFP program provides financial rewards to hospitals whose care performance ranks in the highest quintile relative to peers and reduces funding to hospitals that rank in the lowest quintile. Pay-for-performance is designed to improve care but may disproportionately penalize hospitals caring for large minority populations.

Methods

Using Medicare data, 3449 US hospitals were ranked by performance on PFP process measures for acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and heart failure (HF). These rankings were compared with the percentage of African American (AA) patients in a center. We determined the eligibility for financial bonus (highest quintile ranking) or penalty (lowest quintile) among centers treating large AA populations (≥20%) versus not after adjusting for hospital facility (catheterization, percutaneous coronary intervention, surgery), academic status, number of hospital beds, location, patient volume, and region.

Results

The percentage of AA patients treated by a center was inversely associated with performance for AMI and CAP (P < .01) but not HF (P = .06). Relative to hospitals with <20% AA, those with ≥20% AA were less likely eligible for financial bonuses and more likely to face penalties: for AMI, adjusted odds ratio (OR) 0.7 (95% CI 0.5-1.0) and 1.8 (1.4-2.4), respectively; for CAP, OR 0.5 (95% CI 0.3-0.6) and 2.3 (1.8-2.9), respectively; for HF, OR 1.0 (95% CI 0.7-1.2) and 1.2 (0.9-1.5), respectively.

Conclusions

Hospitals with large minority populations may be at financial risk under PFP. Thus, PFP may worsen existing racial care disparities.

Section snippets

Data source

Data were gathered from 3 sources. First, hospital-level process performance data were obtained from the publicly available Hospital Compare Database in 2006, which consisted of data from 2004 quarter 2 to 2005 quarter 1. Created by CMS in 2001, the Hospital Compare Web site provides up-to-date information on hospital quality. Second, racial demographics were collected from a 5% sample of Medicare Claims data. Third, hospital characteristics were obtained from the American Hospital Association

Study population and hospital characteristics

Of the 5714 hospitals from the Medicare Claims data set, a total of 3449 hospitals were included in this study after excluding those hospitals with ≤10 patients, those without performance data, and those for which hospital characteristic data were unavailable. For AMI, CAP, and HF, we also excluded 1063, 152, and 294 hospitals with ≤30 eligibility for any given measure, respectively. This left a sample of 2386 hospitals for AMI, 3297 for CAP, and 3155 for HF (Figure 1). Relative to hospitals

Discussion

This study is one of the first to explore the relationship between patient race and PFP. Using publicly available Medicare data for patients treated at 3449 US hospitals, we found that hospitals caring for large AA populations scored worse on process performance for certain conditions, namely, AMI and CAP, but not for HF. Even after adjustment for hospital characteristics, hospitals treating large minority populations were associated with poorer process performance for AMI and CAP. These

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: This study was funded by Duke Clinical Research Institute, Durham, NC.

View full text

Clinical InvestigationOutcomes, Health Policy, and Managed CarePotential unintended financial consequences of pay-for-performance on the quality of care for minority patients

Objectives

Background

Methods

Results

Conclusions

Section snippets

Data source

Study population and hospital characteristics

Discussion

Am Heart J

Am Heart J

J Am Coll Cardiol

Examination of racial differences in the management of cardiovascular disease

J Am Coll Cardiol

Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction

N Engl J Med

Geographic variation in the treatment of acute myocardial infarction: the Cooperate Cardiovascular Project

JAMA

Time to presentation with acute myocardial infarction the elderly: associations with race, sex, and socioeconomic characteristics

Circulation

Racial variations in processes of care for patients with community acquired pneumonia

BMC Health Serv Res

Racial variations in treatment and outcomes of black and white patients with high risk non–ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?)

Circulation

Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs

JAMA

Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease

Circulation

Hospital Compare

Clinical Investigation
Outcomes, Health Policy, and Managed Care
Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients