So-called safety-net hospitals take in a lot of patients on government insurance - which doesn't pay as much for services as private insurance - or without any insurance at all, leaving them often under financial stress and struggling to stay open, researchers said.

Under the Affordable Care Act, a small proportion of Medicare and Medicaid funding going to hospitals will be determined by performance measures, including how patients rate their experiences there.

That's not a bad idea in general, said Dr. Ashish Jha from the Harvard School of Public Health in Boston, who worked on the study. But, he added, "We don't actually know how the safety net is going to fare under those payment changes."

His new research, published Monday in the Archives of Internal Medicine, suggests patients treated at safety-net hospitals consistently rate their in-hospital experiences - including their communication with doctors and how their pain is managed - as slightly worse than patients at other hospitals. That finding is based on surveys in 2007 and 2010 of people treated at 3,096 hospitals - about a quarter of them safety-net hospitals.

When it came to rating the hospitals overall, 64 percent of patients treated at a safety-net hospital gave it a 9 or 10 out of 10, compared to almost 70 percent giving that score to non-safety-net hospitals. Patients at safety-net hospitals also rated nursing services, discharge information, communication about medications and noise at the hospital as worse than at other facilities.

The study didn't measure any specific medical outcomes, such as the number of patients who died in the hospital or had complications.

Jha told Reuters Health that patient experiences at safety-net hospitals may be especially important, as poor and minority patients are known to have more distrust for the healthcare system.

Although those patient differences could explain some of the way they rate their care, "the bottom line remains that these hospitals are then going to get penalized," Jha said. And adding hits to hospital budgets that are already stretched thin could have wide implications.

"They're the one set of hospitals that will take care of anyone who comes through their door no matter what their ability to pay," Jha said. "When safety-net hospitals shut down, it has huge effects on the entire marketplace."

He said Medicare officials could reach out to safety-net hospitals and give them resources to improve patient care, including overall hospital experience - then reward them if they successfully make those changes.

The authors of a linked editorial agreed that penalizing struggling safety-net hospitals may not be the most effective strategy to improve care.

"The Centers for Medicare and Medicaid Services (CMS) and state Medicaid agencies should design incentive programs that reward SNHs (safety-net hospitals) for improving patient experience and quality with the goal of closing the gap between SNHs and non-SNHs before implementing penalties," according to Dr. Katherine Neuhausen of the University of California, Los Angeles and Dr. Mitchell Katz, from the Los Angeles County Department of Health Services.

Holding hospitals accountable for the care they provide is important, Jha emphasized - but it has to be done in a way that doesn't push safety-net hospitals into bankruptcy.

SOURCE: bit.ly/OdmdoZ Archives of Internal Medicine, online July 16, 2012.

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