A survey of hospital quality improvement activities.

Five years after the Institute of Medicine (IOM) called for a redesigned U.S. health care system, relatively little was known about the extent to which hospitals had undertaken quality improvement (QI) efforts to address deficiencies in patient care. To examine the state of hospital QI activities in 2006, the authors designed and conducted a survey of short-term, general hospitals with 25 or more beds. In a sample of 470 hospitals, they found that many were actively engaged in improvement efforts but that these activities varied in method and impact. Hospitals with high levels of perceived quality, as reflected in assessments by their quality managers, were more likely to have embraced QI as a strategic priority, employed quality practices and processes consistent with IOM aims, fostered staff training and involvement in QI methods, engaged in an array of QI activities and clinical QI strategies, and maintained staffing levels favoring fewer patients per nurse.

Where do I send thee? Does physician-ownership affect referral patterns to ambulatory surgery centers?

For more than three decades, Congress has struggled with potential financial conflicts of interest when physicians share in financial gain from nonprofessional services. This study asks the question: Are physicians who are leading referrers to physician-owned ambulatory surgery centers (ASCs) more likely to send Medicaid patients to hospital outpatient clinics than other patients? The comparison group is physicians who are leading referrers to non-physician-owned ASCs, using data from two metropolitan areas. Findings indicate that physicians at physician-owned facilities are more likely than other physicians to refer well-insured patients to their facilities and route Medicaid patients to hospital outpatient clinics.

The influence of health policy and market factors on the hospital safety net.

OBJECTIVE: To examine how the financial pressures resulting from the Balanced Budget Act (BBA) of 1997 interacted with private sector pressures to affect indigent care provision. DATA SOURCES/STUDY SETTING: American Hospital Association Annual Survey, Area Resource File, InterStudy Health Maintenance Organization files, Current Population Survey, and Bureau of Primary Health Care data. STUDY DESIGN: We distinguished core and voluntary safety net hospitals in our analysis. Core safety net hospitals provide a large share of uncompensated care in their markets and have large indigent care patient mix. Voluntary safety net hospitals provide substantial indigent care but less so than core hospitals. We examined the effect of financial pressure in the initial year of the 1997 BBA on uncompensated care for three hospital groups. Data for 1996-2000 were analyzed using approaches that control for hospital and market heterogeneity. DATA COLLECTION/EXTRACTION METHODS: All urban U.S. general acute care hospitals with complete data for at least 2 years between 1996 and 2000, which totaled 1,693 institutions. PRINCIPAL FINDINGS: Core safety net hospitals reduced their uncompensated care in response to Medicaid financial pressure. Voluntary safety net hospitals also responded in this way but only when faced with the combined forces of Medicaid and private sector payment pressures. Nonsafety net hospitals did not exhibit similar responses. CONCLUSIONS: Our results are consistent with theories of hospital behavior when institutions face reductions in payment. They raise concern given continuing state budget crises plus the focus of recent federal deficit reduction legislation intended to cut Medicaid expenditures.

An update on safety-net hospitals: coping with the late 1990s and early 2000s.

Recent forces have created new financial stress for hospitals but also some relief. This paper explores hospitals' changing involvement in the safety net between 1996 and 2002. We replicate approaches used in a study of 1990-1997 and thus provide a needed update on the U.S. hospital safety net. Overall, some groups of safety-net hospitals increased uncompensated care, but others did not. Non-safety-net hospitals trimmed certain services commonly used by the indigent; this may point to future reductions in access. We examine the implications of these findings for the future of the safety net.