Study: HMOs Use Hospitals With Higher Bypass Death Rate
New York heart patients in managed care groups are more likely to undergo bypass surgery in hospitals with relatively high death rates for the operation than are patients with other kinds of insurance, researchers reported Wednesday.
That finding in the Journal of the American Medical Assn. paints a startling portrait of who lives or dies following heart surgery, based on the hospital chosen for the surgery. Deaths tabulated in the study occurred within hours of the operations, suggesting either a lack of experience for some surgical staffs or something amiss in the nursing skills in the hours following the operation.
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Dr. Lars Erickson, a Harvard University cardiologist, and colleagues gleaned information from New York State Department of Health statistics, examining the fates of 58,902 New Yorkers who sought bypasses between 1993 and 1996. For reasons that have yet to be explained, managed care organizations invariably chose hospitals with higher death rates.
“Their choices are based on negotiated contracts,” Erickson said. “Patients have little to say in the process. The companies are picking where patients go, so the question is why, in a state which for years has published data on the hospitals, why are the companies choosing hospitals that are worse?”
Erickson voiced the hope that his study will serve as a wake-up call to managed care companies, encouraging them to use state mortality data before assigning patients to hospitals.
New York is one of the few states to regularly assess how bypass patients are faring in each hospital where the operation is performed.
State epidemiologists examine risk-adjusted mortality rates at the 32 hospitals where the operation is performed. In the last survey, the average rate of deaths per 100 operations was 2.44%.
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While state health officials have cautioned patients against choosing hospitals based on ratings alone, Erickson said it’s time that managed care companies started looking at them if they want some patients to survive long enough to leave the hospital.
Compared with patients who have private fee-for-service insurance, those with private managed care insurance were 23% less likely to receive coronary bypass operations at hospitals with favorable survival rates. Medicare managed care patients were 39% less likely to undergo operations at hospitals with favorable rates, the study showed.
Despite Erickson’s exhaustive study, Dr. Stephen Jencks of the Health Care Financing Administration, which oversees Medicare, asks whether comparative hospital data really tell patients much about doctors’ skills. Many of the patients in the study participated in Medicare HMO plans.
“Comparative data does not automatically produce improved clinical performance,” Jencks wrote in an accompanying JAMA editorial. “For years,” he added, “there was serious debate as to whether quality of care was measurable at all.”
