THCB

Hospital Quality Under Scrutiny

Last week’s New York Times article on cardiac care at some HCA-owned hospitals yielded a chorus of comments from readers who argued that for-profit hospital care is inherently low-quality care. As it happened, in working on a history of the investor-owned hospital sector, I had just been crunching data that might either support or refute that assertion. The results are surprising, if far from decisive.

Last September, the Joint Commission released the first of what it said would be annual lists recognizing “Top Performers on Key Quality Measures™” among the nation’s accredited hospitals. The all-star roster is based on “core measure performance data” that hospitals report to the Commission. The data cover adherence to “accountability measures ” established as best practice in the eyes of the Commission – making sure to prescribe beta-blockers for heart attack patients at discharge, for example, or to discontinue prophylactic antibiotics within 24 hours after surgery.

Unlike hospital quality measures that look at results – death rates and other outcomes – this one looks at processes. In theory, then, it ought to be more fair to hospitals that tend to serve sicker or more compromised patients, such as government-run hospitals in inner cities.

The 405 hospitals that made the list represent the top 14 percent of accredited institutions that chose to report the data for this optional program. If 14 percent is a fair baseline expectation, I wondered, how would hospitals operated by for-profit chains fare against it? I did my best to identify all the hospitals on the list belonging to each chain – not as simple an exercise as it sounds; I stand ready to correct the data if I missed or misidentified any facility – and I tallied the percentage of all hospitals that made the grade in the case of each chain. The chart above shows how the numbers came out.

For-profit entities operate at least 167 of the 405 recognized facilities, by my count – some 41 percent of the total.

As the chart indicates, most of the major investor-owned hospital companies substantially outperformed the 14 percent national average. Prime Healthcare – which a California activist group has targeted for alleged patient care lapses – ranked first at 69 percent. HCA – which said late last week that another Times exposé on patient care may be in the offing – came in at 46 percent. Four chains were entirely absent from the list, but it’s not clear whether they submitted the necessary data to the Commission.

There’s much to debate in these numbers. Do they show that for-profit hospitals dramatically outperform their non-profit peers in clinical quality, nevermind the hue and cry against corporate medicine in many quarters? Have the for-profits found a way to game this system, as they so successfully game Medicare and other systems? Is there something about the Joint Commission’s standards that tends to boost the scores of investor-owned facilities? And are those standards the right ones to use in assessing the quality of care?

E. Thomas Wood is a journalist and historian in Nashville. For his upcoming history of for-profit healthcare provision , he has interviewed many of that industry’s forefathers. He welcomes contacts from anyone with a story to offer about the investor-owned hospital business: tom@ethomaswood.com .

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James BertschBill SpringerE. Thomas Woodsm2012David Whelan Recent comment authors
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E. Thomas Wood
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Update: The Joint Commission has just released its 2011 list of Top Performers — http://www.pwrnewmedia.com/2012/joint_commission/annual_report/downloads/TJC_Annual_Report_embargo_2012.pdf.

I hope to have time to run the FP/NFP numbers on this one soon.

James Bertsch
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James Bertsch

This is not surprising at all. For-profit hospitals, expectedly, gain market leadership through high quality and specialization. The three questions, which make the most sense are: 1) Is the hospital a full-service hospital, i.e., does it keep or eliminate unprofitable lines of care? 2) Are they a full-access hospital or do they have a policy to move patients without insurance (non-paying) to a government owned facility? 3) If a patient is uninsured. do they increase their rates? The USA for-profit health care system delivers high quality care for paying patients with good general health. Problematic chronic patients and non-paying patients… Read more »

Bill Springer
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Bill Springer

One could also posit that for profit hospitals will perform better on measures that are new and that reflect their ability to adapt to market opportunities. It would be quite interesting to see if the ranking of for profits changes based on the “maturity” of the measure, i.e., the longer it has been in place, the less likely they are to outperform their nonprofit counterparts.

E. Thomas Wood
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E. Thomas Wood
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David and SM–

Thanks for the thought-provoking responses. I posit no answers; just glad to see that others also feel the questions are important.

-Tom

sm2012
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Tom, you’ve nailed the questions. And as David comments, it should really give us pause as the era of big data, public reporting, and pay for quality shape how care is delivered. 1. ‘Do they show that for-profit hospitals dramatically outperform their non-profit peers in clinical quality, nevermind the hue and cry against corporate medicine in many quarters? ‘ – if there is really something to be learned from the for profits, rather than getting better outcomes by just cherry picking the least sick patients, then let’s figure out what the processes are that they use and make them standard… Read more »

David Whelan
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David Whelan

Prime is the best? That would surprise all of Prem Reddy’s naysayers in California.

It either means that the activists, as you say, are wrong. Or that these process measurements are unhelpful.