Quality of care at safety-net hospitals and the impact on pay-for-performance reimbursement

Background: Pay-for-performance reimbursement ties hospital payments to standardized quality of care metrics. The impact of pay-for-performance reimbursement models on safety-net hospitals, which care primarily for uninsured or underinsured patients, remains poorly defined. This study evaluates how standardized quality of care metrics vary by a hospital9s safety-net status, and helps us better understand the potential impact that pay-for-performance reimbursement could have on funding of safety-net hospitals. Methods: We identified 1,703,865 bladder, breast, cervix, colon, endometrium, gastric, lung, ovary, or rectum cancer patients treated at 1,344 hospitals diagnosed between 2004 and 2015. Safety-net burden was defined for each hospital as the percentage of uninsured or Medicaid patients cared for by that hospital. Hospitals were grouped into low-, medium-, and high-burden hospitals. We evaluated the impact of safety-net burden on concordance with 20 standardized quality of care measures, adjusting for differences in patient age, gender, stage at diagnosis, and comorbidity. Results: Patients seen at high-burden hospitals were more likely to be young, male, black, Hispanic, and to reside in a low-income and low-educated region. High-burden hospitals had lower adherence to 13 of 20 quality measures compared to low-burden hospitals (all p<0.05). Among the 350 high-burden hospitals, the quality measures were lowest for those caring for the highest fraction of uninsured or Medicaid patients, minority serving hospitals, and those caring for less educated patients (all p<0.001). Discussion: Cancer care at safety-net hospitals was associated with lower concordance to standardized quality of care measures. Under a pay-for-performance reimbursement model these lower quality of care scores could decrease payments to safety-net hospitals, potentially increasing health disparities for at-risk cancer patients.