Werner Rachel M, Goldman L Elizabeth, Dudley R Adams
Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania 19104, USA.
JAMA. 2008 May 14;299(18):2180-7. doi: 10.1001/jama.299.18.2180.
Safety-net hospitals (ie, those that predominantly treat poor and underserved patients) often have lower quality of care than non-safety-net hospitals. While public reporting and pay for performance have the potential to improve quality of care at poorly performing hospitals, safety-net hospitals may be unable to invest in quality improvement. As such, some have expressed concern that these incentives have the potential to worsen existing disparities among hospitals.
To examine trends in disparities of quality of care between hospitals with high and low percentages of Medicaid patients.
Longitudinal study of the relationship between hospital performance and percentage Medicaid coverage from 2004 to 2006, using publicly available data on hospital performance. A simulation model was used to estimate payments at hospitals with high and low percentages of Medicaid patients.
Changes in hospital performance between 2004 and 2006, estimating whether disparities in hospital quality between hospitals with high and low percentages of Medicaid patients have changed.
Of the 4464 participating hospitals, 3665 (82%) were included in the final analysis. Hospitals with high percentages of Medicaid patients had worse performance in 2004 and had significantly smaller improvement over time than those with low percentages of Medicaid patients. Hospitals with low percentages of Medicaid patients improved composite acute myocardial infarction performance by 3.8 percentage points vs 2.3 percentage points for those with high percentages, an absolute difference of 1.5 (P = .03). This resulted in a relative difference in performance gains of 39%. Larger performance gains at hospitals with low percentages of Medicaid patients were also seen for heart failure (difference of 1.4 percentage points, P = 0.04) and pneumonia (difference of 1.3 percentage points, P <.001). Over time, hospitals with high percentages of Medicaid patients had a lower probability of achieving high-performance status. In a simulation model, these hospitals were more likely to incur financial penalties due to low performance and were less likely to receive bonuses.
Safety-net hospitals tended to have smaller gains in quality performance measures over 3 years and were less likely to be high-performing over time than non-safety-net hospitals. An incentive system based on these measures has the potential to increase disparities among hospitals.
安全网医院（即主要治疗贫困和服务不足患者的医院）的医疗质量往往低于非安全网医院。虽然公开报告和按绩效付费有可能提高表现不佳医院的医疗质量，但安全网医院可能无力投资于质量改进。因此，一些人担心这些激励措施有可能加剧医院之间现有的差距。
研究医疗补助患者比例高和低的医院之间医疗质量差距的趋势。
对2004年至2006年医院绩效与医疗补助覆盖比例之间的关系进行纵向研究，使用公开可得的医院绩效数据。采用模拟模型估计医疗补助患者比例高和低的医院的支付情况。
2004年至2006年期间医院绩效的变化，估计医疗补助患者比例高和低的医院之间的医疗质量差距是否发生了变化。
在4464家参与研究的医院中，3665家（82%）纳入最终分析。2004年，医疗补助患者比例高的医院表现较差，且随着时间推移其改善幅度明显小于医疗补助患者比例低的医院。医疗补助患者比例低的医院综合急性心肌梗死绩效提高了3.8个百分点，而比例高的医院为2.3个百分点，绝对差值为1.5（P = 0.03）。这导致绩效提升的相对差值为39%。在心力衰竭（差值为1.4个百分点，P = =0.04）和肺炎（差值为1.3个百分点，P <0.001）方面，医疗补助患者比例低的医院也有更大的绩效提升。随着时间推移，医疗补助患者比例高的医院达到高绩效状态的概率较低。在模拟模型中，这些医院因表现不佳而更有可能受到经济处罚，获得奖金的可能性也较小。
在三年时间里，安全网医院在质量绩效指标方面的提升往往较小，而且随着时间推移，与非安全网医院相比，其成为高绩效医院的可能性较小。基于这些指标的激励系统有可能加剧医院之间的差距。
