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: firstname.lastname@example.org .
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.
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 are denied access to high quality care and are untreated or treated in a minimalistic fashion.
We all age. If we are lucky enough to retire and reach a ripe old age, we become uninsured problematic patients with chronic disorders, who place unprofitable demands on the health care system.
Without government sponsored programs (social security, medicare and medicaid) and hospitals, most all of us become unhealthy, uninsured (non-paying) patients who are denied access entirely or only receive minimalistic care.
Quality of care is meaningless, when it is not delivered to patients in need.
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.
And now the Times has let the other shoe drop:
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, 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 of care.
2. ‘Have the for-profits found a way to game this system, as they so successfully game Medicare and other systems?’ – having consulted for hospitals who are struggling with their quality ratings when they KNOW intuitively that the care they provide is better than the neighboring better rated hospital, this is the biggest gripe. That coding and gaming patient selection can make a lesser quality facility look better.
3. ‘Is there something about the Joint Commission’s standards that tends to boost the scores of investor-owned facilities?’ – super interesting. A corollary question…do the standards set by JCAHO actually provide meaningful quality measures or are they just checklist items that administrators have to comply with during the dreaded JCAHO visits.
4. ‘And are those standards the right ones to use in assessing the quality of care?’ – and this is the ultimate question that relates to the others. How do we measure good quality. Is it short term medical complications to surgical procedures, is it how many infections occur, is it readmissions, or longer term functional outcomes? It seems like the ‘governing bodies’ at both state and federal levels come up with a set of goals, that many clinical people don’t necessarily find relevant (think Core Measures). But they get pushed as some criteria that we can measure that may be valuable, and we all start to chase the goals that are set out for us. And in every system where there are rewards and victors, there are those that cheat or game the system whether or not the goals actually help us reach our more broad aim of caring well for others.
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.