Measuring the quality of care in a hospital is an extraordinarily difficult undertaking, but the federal Medicare program is making a major push to do just that - in a bid to tame budget-busting health-care spending.
Starting in the new year, Medicare officials will reward or punish hospitals based on how consistently they fulfilled a dozen standards of care and how patients rated the care they received.
In the Philadelphia region, 18 hospitals are being penalized and 22 will get a bonus from Medicare, based on past performance, according to government data released this month and provided by Kaiser Health News. Two hospitals are breaking even.
Nationwide, the amount of money at stake under the program is $982 million, Kaiser reported. Medicare is taking the lead because its elderly beneficiaries are the most intense users of health-care services.
The amounts for individual hospitals are not huge, but experts said it makes sense to take small steps in the sweeping but gradual transition toward financially rewarding the quality of care, rather than the amount of care provided.
"It's going slowly because they are afraid of making a mistake," Michael D. Rosko, a professor of health-care management at Widener University, said of the authorities. "The intention over time is to broaden it significantly."
The biggest Medicare winner locally, based on so-called process of care and patient satisfaction standards, is the Bucks County Specialty Hospital in Bensalem, an orthopedic facility majority-owned by the Rothman Institute. It will receive a 0.67 percent bonus over standard Medicare payments.
St. Joseph's Hospital, part of North Philadelphia Health System, is the biggest loser. It will see a 0.78 percent reduction in its quality-based Medicare payments through September.
Medicare looked at how consistently hospitals gave heart attack patients medication to avert blood clots within 30 minutes of arrival, among other standards.
Just after Medicare administrators released their quality data Dec. 20, a Pennsylvania agency put out a study on how hospitals handled 12 medical conditions and procedures.
In its report, the Pennsylvania Health Care Cost Containment Council flagged hospitals that in 2011 had higher-than-expected readmissions within 30 days of discharge.
That report, without direct financial consequences, also compared hospitals based on the number of patients who died during a stay. It adjusted the outcomes to account for variations in how sick the patients were when they arrived.
Experts said such yardsticks remain imperfect.
"The idea of paying for quality everybody agrees on, but when you see it in practice it is kind of ugly. There's a lot of noise," said Daniel E. Polsky, executive director of the University of Pennsylvania's Leonard Davis Institute of Health Economics.
In the Pennsylvania study, Roxborough Memorial had the most mortality rates that exceeded expectations for particular conditions or procedures. That expectation is based on how sick the patients were.
Roxborough's higher-than-expected rates were in chronic heart failure, diabetes, kidney and urinary tract infections, and pneumonia caused by breathing food, drink, or other matter into the lungs.
"We've been working on improving our outcome measures since we purchased both hospitals," said Peter Adamo, regional chief executive for Prime Healthcare Services Inc., which bought Roxborough, in Philadelphia, in February, and Lower Bucks Hospital, in Bristol, in the fall.
The Pennsylvania report found that Mercy Fitzgerald Hospital, in Darby, and Philadelphia's Thomas Jefferson University Hospital each had higher than expected readmission rates in five areas, the highest among 39 area institutions studied. The readmission can be for any reason.
Jefferson held a summit recently to improve coordination with nursing homes and others in a bid to prevent patients from quickly landing back in the hospital, said Rachel Sorokin, the hospital's chief patient safety and quality officer.
According to the Medicare quality data released this month, Lower Bucks faces a 0.49 percent reduction in Medicare payments because of low scores for standards of care. That is the second biggest hit in the region.
Just behind Lower Bucks, Lourdes Medical Center of Burlington County in Willingboro will get a 0.47 percent Medicare cut.
Mark Nessel, chief operating officer at Lourdes Health System, said the organization was confident that "based on the measures we have put in place over the past year that our results will improve in the next evaluation period."
David L. Knowlton, chief executive of the New Jersey Health Care Quality Institute in Pennington, said every hospital should get a top score on following standards of care.
"You shouldn't be in practice if you can't get an A," Knowlton said.