Assessments of hospital quality, including patient-experience surveys, that are tied to payment penalties should account for social-risk factors that can disproportionately affect the safety-net hospitals that serve America’s most vulnerable patient populations, says new policy adopted at the 2017 AMA Interim Meeting in Honolulu.

It is one of several actions taken by the AMA House of Delegates (HOD), pursuant to a report from  the AMA Council on Medical Service. The council studied the impact Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys had on Medicare payments to hospitals serving vulnerable populations.

“The council recommends policy to help shield safety-net hospitals from the potentially negative financial impact that hospital quality-program assessments may have on hospitals that serve a disproportionate share of patients with social-risk factors and policy to recognize the importance of cultural competency in patient experience and treatment-plan adherence,” says the council’s report, which was adopted without amendment at the 2017 AMA Interim Meeting in Honolulu.

Avoiding unintended consequences

The report cites a 2012 JAMA Internal Medicine study finding that hospitals serving a disproportionate share of low-income and Medicaid patients generally scored lower than other hospitals in HCAHPS surveys and were 60 percent less likely to meet performance benchmarks under Medicare’s Value-Based Purchasing (VBP) program.

“The AMA must guard against efforts aimed at improving the quality of care that have the unintentional effect of stripping safety-net hospitals of needed funding and thereby exacerbating health care disparities,” the report says. “Tying financial incentives to HCAHPS patient-satisfaction scores may have the effect of financially penalizing such hospitals and unintentionally exacerbating existing inequalities in care.”

The report recommended several related new policies that the HOD adopted. These included calls for the AMA to:

  • Support that the goal of hospital quality program assessments should be to identify areas to improve patient outcomes and the quality of patient care.
  • Recognize the importance of cultural competency to patient experience and treatment-plan adherence and encourage the implementation of cultural competency practices across health care settings.
  • Support that hospital quality program assessments should account for social-risk factors so that they do not have the unintended effect of financially penalizing safety-net hospitals and exacerbating health care disparities.
  • Continue to advocate for better risk models that account for social-risk factors in hospital quality program assessments.
  • Continue to work with Centers for Medicare & Medicaid Services and other stakeholders, including representatives from the safety-net hospital trade group, America’s Essential Hospitals, to address issues related to hospital quality program assessments.

Delegates added one more new policy to this list, saying the AMA should “oppose hospital quality program assessments that have the effect of financially penalizing physicians, including those practicing in safety-net hospitals.”

The HOD also reaffirmed existing policy that directs the AMA to:

  • Emphasize that quality measures should adjust for factors that are not within control of those being measured.
  • Support efforts to continue to improve patient-satisfaction measures and to document its relationship to favorable outcomes.
  • Promote cultural competency training with the goal of emphasizing cultural competence as part of professional practice.

Perception can affect outcomes

While noting that patient satisfaction may not necessarily be an indicator of quality, the report states that valuable information can be gleaned from patient surveys.

The report adds that positive patient perception is important for shared decision-making, adherence to treatment plans and as a reflection of the patient-physician relationship.

“The council believes improving the patient experience is a shared goal in health care,” the report concludes. “It also believes that ensuring the financial viability of safety-net hospitals is vital to providing care to the most vulnerable and fighting to reduce health care disparities.”


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