The Relationship Between Reimbursement and Quality of Care for Patients Hospitalized with Heart Failure

Data supporting the existence of a relationship between reimbursement and quality are limited. We assessed the association between quality of care for 34,318 patients hospitalized with heart failure across the US and heart failure Diagnosis-Related Group (DRG) payment for the 3,905 hospitals at which patients were admitted. Payment varied from $2606 to $11,845. We found a discontinuous relationship between documentation of ejection fraction and payment; below $4200, there was a steep increase in rates of the quality indicator with increasing DRG payment (OR 1.15 for each $100 increase, 95% CI 1.12-1.18). For ACE inhibitor prescription, the increase in rates below the threshold was of borderline significance (OR 1.04 for each $100 increase, 95% CI 1.00-1.07). Hospitals with reimbursement below the threshold were more likely non-urban (p<0.001), public (p<0.0001), and without advanced cardiac facilities (p<0.0001), and had fewer full-time registered nurses per adjusted patient-day (p<0.0001). We conclude that hospitals with low rates of Medicare DRG-based reimbursement have lesser performance on a heart failure quality measure, perhaps because of difficulty investing in advanced cardiac facilities or maintaining patient care staffing.