Association of the Medicare Value-Based Purchasing Program With Changes in Patient Care Experience at Safety-net vs Non–Safety-net Hospitals

IMPORTANCE: Safety-net hospitals, which have limited financial resources and care for disadvantaged populations, have lower performance on measures of patient experience than non–safety-net hospitals. In 2011, the Centers for Medicare & Medicaid Services Hospital Value-Based Purchasing (VBP) program began tying hospital payments to patient-reported experience scores, but whether implementation of this program narrowed differences in scores between safety-net and non–safety-net hospitals is unknown. OBJECTIVE: To evaluate whether the VBP program’s implementation was associated with changes in measures of patient-reported experience at safety-net hospitals compared with non–safety-net hospitals between 2008 and 2019. DESIGN, SETTING, AND PARTICIPANTS: This cohort study evaluated 2266 US hospitals that participated in the VBP program between 2008 and 2019. Safety-net hospitals were defined as those in the highest quartile of the disproportionate share hospital index. Data were analyzed from December 2021 to February 2022. MAIN OUTCOMES AND MEASURES: The primary outcomes were the Hospital Consumer Assessment of Healthcare Providers and Systems global measures of patient-reported experience and satisfaction, including a patient’s overall rating of a hospital and willingness to recommend a hospital. Secondary outcomes included the 7 other Hospital Consumer Assessment of Healthcare Providers and Systems measures encompassing communication ratings, clinical processes ratings, and hospital environment ratings. Piecewise linear mixed regression models were used to assess annual trends in performance on each patient experience measure by hospital safety-net status before (July 1, 2007-June 30, 2011) and after (July 1, 2011-June 30, 2019) implementation of the VBP program. RESULTS: Of 2266 US hospitals, 549 (24.2%) were safety-net hospitals. Safety-net hospitals were more likely than non–safety-net hospitals to be nonteaching (67.6% [371 of 549] vs 53.1% [912 of 1717]; P < .001) and urban (82.5% [453 of 549] vs 77.4% [1329 of 1717]; P = .01). Safety-net hospitals consistently had lower patient experience scores than non–safety-net hospitals across all measures from 2008 to 2019. The percentage of patients rating safety-net hospitals as a 9 or 10 out of 10 increased during the pre-VBP program period (annual percentage change, 1.84%; 95% CI, 1.73%-1.96%) and at a slower rate after VBP program implementation (annual percentage change, 0.49%; 95% CI, 0.45%-0.53%) at safety-net hospitals. Similar patterns were observed at non–safety-net hospitals (pre-VBP program annual percentage change, 1.84% [95% CI, 1.77%-1.90%] and post-VBP program annual percentage change, 0.42% [95% CI, 0.41%-0.45%]). There was no differential change in performance between these sites after the VBP program implementation (adjusted differential change, 0.07% [95% CI, −0.08% to 0.23%]; P = .36). These patterns were similar for the global measure that assessed whether patients would definitely recommend a hospital. There was also no differential change in performance between safety-net and non–safety-net hospitals under the VBP program across measures of communication, including doctor (adjusted differential change, −0.09% [95% CI, −0.19% to 0.01%]; P = .08) and nurse (adjusted differential change, −0.01% [95% CI, −0.12% to 0.10%]; P = .86) communication as well as clinical process measures (staff responsiveness adjusted differential change, 0.13% [95% CI, −0.03% to 0.29%]; P = .11; and discharge instructions adjusted differential change, −0.02% [95% CI, −0.12% to 0.07%]; P = .62). CONCLUSIONS AND RELEVANCE: This cohort study of 2266 US hospitals found that the VBP program was not associated with improved patient experience at safety-net hospitals vs non–safety-net hospitals during an 8-year period. Policy makers may need to explore other strategies to address ongoing differences in patient experience and satisfaction, including additional support for safety-net hospitals.