Collateral Damage: Pay-for-Performance Initiatives and Safety-Net Hospitals
Authors: Steffie Woolhandler, David U. Himmelstein
Journal: Annals of Internal Medicine (2015)

Editorials15 September 2015Collateral Damage: Pay-for-Performance Initiatives and Safety-Net HospitalsSteffie Woolhandler, MD, MPH and David U. Himmelstein, MDSteffie Woolhandler, MD, MPHFrom City University of New York School of Public Health at Hunter College, New York, New York.Search for more papers by this author and David U. Himmelstein, MDFrom City University of New York School of Public Health at Hunter College, New York, New York.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M15-1393 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A century ago, Abraham Flexner's effort to upgrade medical education closed underresourced schools that provided almost all of the training opportunities available to black and female physicians. Six decades passed before medical schools—prodded by the civil rights and women's movements—began restoring opportunities for these groups.In this issue, Gilman and colleagues (1) document an analogous side effect of Medicare's pay-for-performance (P4P) initiatives: They divert money from underresourced safety-net hospitals that are mainstays of care in many minority communities to hospitals serving more affluent patients.This worrisome finding is not unexpected. Even excellent physicians who care for disadvantaged patients often score ...References1. Gilman M, Hockenberry JM, Adams EK, Milstein AS, Wilson IB, Becker ER. The financial effect of value-based purchasing and the Hospital Readmissions Reduction Program on safety-net hospitals in 2014. A cohort study. Ann Intern Med. 2015;163:427-36. doi:10.7326/M14-2813 LinkGoogle Scholar2. Hong CS, Atlas SJ, Chang Y, Subramanian SV, Ashburner JM, Barry MJ, et al. Relationship between patient panel characteristics and primary care physician clinical performance rankings. JAMA. 2010;304:1107-13. [PMID: 20823437] doi:10.1001/jama.2010.1287 CrossrefMedlineGoogle Scholar3. McFarland DC, Ornstein KA, Holcombe RF. Demographic factors and hospital size predict patient satisfaction variance-implications for hospital value-based purchasing. J Hosp Med. 2015. [PMID: 25940305] doi:10.1002/jhm.2371 CrossrefMedlineGoogle Scholar4. Kind AJ, Jencks S, Brock J, Yu M, Bartels C, Ehlenbach W, et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med. 2014;161:765-74. [PMID: 25437404] doi:10.7326/M13-2946 LinkGoogle Scholar5. Jha AK, Joynt KE, Orav EJ, Epstein AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med. 2012;366:1606-15. [PMID: 22455751] doi:10.1056/NEJMsa1112351 CrossrefMedlineGoogle Scholar6. Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. N Engl J Med. 2012;367:1821-8. [PMID: 23134382] doi:10.1056/NEJMsa1114951 CrossrefMedlineGoogle Scholar7. Kristensen SR, Meacock R, Turner AJ, Boaden R, McDonald R, Roland M, et al. Long-term effect of hospital pay for performance on mortality in England. N Engl J Med. 2014;371:540-8. [PMID: 25099578] doi:10.1056/NEJMoa1400962 CrossrefMedlineGoogle Scholar8. Propper C, Burgess S, Gossage D. Competition and quality: evidence from the NHS internal market 1991-9. Economic J. 2008;118:138-70. CrossrefGoogle Scholar9. Cooper AL, Kazis LE, Dore DD, Mor V, Trivedi AN. Underreporting high-risk prescribing among Medicare Advantage plans: a cross-sectional analysis. Ann Intern Med. 2013;159:456-62. [PMID: 24081286] doi:10.7326/0003-4819-159-7-201310010-00005 LinkGoogle Scholar10. Deci EL, Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999;125:627-68. [PMID: 10589297] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From City University of New York School of Public Health at Hunter College, New York, New York.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1393.Corresponding Author: Steffie Woolhandler, MD, MPH, City University of New York School of Public Health at Hunter College, 255 West 90th Street, New York, NY 10024; e-mail, [email protected]cuny.edu.Current Author Addresses: Drs. Woolhandler and Himmelstein: City University of New York School of Public Health at Hunter College, 255 West 90th Street, New York, NY 10024.This article was published online first at www.annals.org on 8 September 2015. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014 Matlin Gilman , Jason M. Hockenberry , E. Kathleen Adams , Arnold S. Milstein , Ira B. Wilson , and Edmund R. Becker The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014 Matlin Gilman , Jason M. Hockenberry , E. Kathleen Adams , Arnold S. Milstein , Ira B. Wilson , and Edmund R. Becker Collateral Damage: Pay-for-Performance Initiatives Steffie Woolhandler and David U. Himmelstein Collateral Damage: Pay-for-Performance Initiatives Mitchel L. Galishoff Metrics Cited bySafety‐net hospital performance under Comprehensive Care for Joint ReplacementAssociation between Medicare’s Hospital Readmission Reduction Program and readmission rates across hospitals by medicare bed shareFinancial Performance of Hospitals in the Appalachian Region Under the Hospital Readmissions Reduction Program and Hospital Value‐Based Purchasing ProgramLiver transplantation at safety net hospitals: Potentially vulnerable patients with noninferior outcomesDid Performing Community Health Needs Assessments Increase Community Health Program Spending by North Carolina's Tax-Exempt Hospitals?Primary care clinicians’ perspectives about quality measurements in safety-net clinics and non-safety-net clinicsMedicare Payment Penalties and Safety Net Hospital Profitability: Minimal Impact on These Vulnerable HospitalsPhysician Perception of Pay Fairness and its Association with Work Satisfaction, Intent to Leave Practice, and Personal HealthReassessing Post-Hospital Conditions of Section 3025 Hospital Readmissions Reduction Program in the Affordable Care ActThe unintended consequences of The Centers for Medicare and Medicaid Services pay-for-performance structures on safety-net hospitals and the low-income, medically vulnerable populationHistory Bias, Study Design, and the Unfulfilled Promise of Pay-for-Performance Policies in Health CareCollateral Damage: Pay-for-Performance InitiativesMitchel L. Galishoff, MDPhysician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Telling Us 15 September 2015Volume 163, Issue 6Page: 473-474KeywordsDeath ratesDisclosureMedicareMortalityMotivationPatientsPrevention, policy, and public healthStarvationSurgeryTaxes ePublished: 15 September 2015 Issue Published: 15 September 2015 Copyright & PermissionsCopyright © 2015 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...