Press Release

Embargoed Until Contact

October 06, 2011

Sue Ducat
Director of Communications
(301) 841-9962


Worst Hospitals Treat Twice As Many Minorities And Poor Patients As Best Hospitals, Also Yield Worse Outcomes: New Study


Movement to Value-Based Purchasing Could Further Disadvantage High-Cost, Low-Quality Institutions and Exacerbate Disparities in Care


Bethesda, MD--The nation's 178 "worst" hospitals--the lowest-quality, highest-cost institutions--care for more than twice the proportion of elderly minority and poor patients as the nation's 122 "best" hospitals, where costs are lowest and quality highest. What's more, the patients at the worst institutions are more likely than patients elsewhere to die of certain conditions, such as heart attacks and pneumonia. And these hospitals and their patients may be the ones most at risk under new Medicare payment arrangements that could cut payments to hospitals that fail to meet quality metrics.


The study, by lead author Ashish K. Jha from the Harvard School of Public Health, and colleagues examined the associations among quality, costs and types of patients served in approximately 3,200 hospitals nationwide, and it appears in the October 2011 issue of Health Affairs, "Agenda For Fighting Disparities." The researchers then identified 122 "best" hospitals (those that were in the highest quartile of quality and lowest quartile of risk-adjusted costs) and 178 "worst" hospitals (those in the lowest quartile of quality and the highest quartile of costs). The authors found that elderly black people constituted nearly 15 percent of the patients in the worst hospitals compared to 6.8 percent in the best hospitals. Patients with myocardial infarction or pneumonia who were admitted to low-cost, low-quality hospitals or high-cost, low-quality hospitals were more likely to die (12-19 percent and 7-10 percent, respectively) than similar patients admitted to the best hospitals.

The worst hospitals were smaller than the best hospitals, were usually for-profit or public, and tended to be located in the South. The best hospitals were typically nonprofit institutions located in the Northeast region of the United States and were often equipped with cardiac intensive care units. The best hospitals also treated a higher proportion of Medicare patients than the worst hospitals.


The study authors also warned about the implications for poorer and minority patients served by the worst hospitals of new Medicare payment arrangements scheduled to take full effect in 2013. Under the new national value-based purchasing system, the federal government will grant higher payments to high-quality, efficient hospitals that meet specific quality metrics and will cut payments to institutions that fail to meet them or to improve.


"There are a lot of already disadvantaged hospitals that will not do well in this environment, and there will be significant consequences for their patients," says lead study author Jha, an associate professor of health policy at the Harvard School of Public Health. "While value-based purchasing is well-intended, many hospitals that disproportionately care for minorities and the poor will fare poorly because they will have to improve quality to avoid financial penalties in an environment where overall payment rates are declining. We will have to track closely to make sure we don't inadvertently worsen health care disparities in the process of promoting quality and efficiency," Jha says.


The study was funded by The Commonwealth Fund. E. John Orav, an associate professor of medicine at Harvard Medical School, and Arnold M. Epstein, chair, Department of Health Policy and Management at the Harvard School of Public Health, coauthored the study. The October issue of Health Affairs is supported by the Aetna Foundation.


Jha and colleagues also examined the characteristics of high-quality, high-cost hospitals. These tended to be major teaching hospitals, located in urban areas, and to have much higher nurse-to-patient ratios than other institutions. The high-cost, high-quality institutions also earned much higher patient satisfaction scores than other hospitals.


More nurses on staff could be the reason that patients have better experiences during their hospital stay, says Jha. Hospitals with much higher costs may be spending the extra money to attend to things that their patients value-- like having greater access to a nurse when they need something.


"In the move towards greater efficiency, we want to make sure hospitals don't cut things that optimize patient hospital experiences," says Jha.

About Health Affairs

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at You can also find the journal on Facebook and Twitter and download Narrative Matters on iTunes. Address inquiries to Sue Ducat at (301) 841-9962 or