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Kyalwazi AN, Narasimmaraj P, Xu J, Song Y, Wadhera RK. Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults. Health Aff (Millwood) 2024; 43:118-124. [PMID: 38190594 DOI: 10.1377/hlthaff.2023.00740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.
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Affiliation(s)
| | | | - Jiaman Xu
- Jiaman Xu, Beth Israel Deaconess Medical Center
| | - Yang Song
- Yang Song, Beth Israel Deaconess Medical Center
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Negele D, Lauerer M, Nagel E, Ulrich V. How to further develop quality competition in the German healthcare system? Results of a Delphi expert study. Health Policy 2023; 138:104937. [PMID: 38039559 DOI: 10.1016/j.healthpol.2023.104937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Many international healthcare systems use quality competition to improve the quality of care. The corresponding instruments include quality measurement, public reporting, selective contracting, and pay for performance. The German healthcare system clearly shows that the possibilities are often limited in the status quo. Therefore, a need for practicable and evidence-based proposals are necessary to further the development of quality competition. METHODS We conducted a national analysis and an international comparison (Switzerland, Netherlands and USA) as a pre-study to derive recommendations. On this basis, we designed a Delphi study with a consensus objective. Experts from relevant stakeholder groups in the German healthcare system were selected using purposive sampling for this study. RESULTS The experts saw potential for quality improvement in the further development of quality competition. Quality measurement and public reporting were rated as empowering tools. There was mostly disagreement on whether quality competition should be further developed in a more regulatory or entrepreneur-based manner. However, there was a clear consensus that further development must be coordinated between the stakeholders, step-by-step and scientifically supported. In addition, the impulse should be supported by a legislatively introduced reform. CONCLUSIONS Finally, these empirically based recommendations highlight the need for a coordinated coexistence of a top-down and a bottom-up approach. The developed blueprint proposal serves as an impetus for practical considerations of implementation.
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Affiliation(s)
- Daniel Negele
- Chair of Public Finance, University of Bayreuth, VWL III, Bayreuth 95447, Germany; Institute for Medical Management and Health Sciences, University of Bayreuth, Bayreuth 95444, Germany.
| | - Michael Lauerer
- Institute for Medical Management and Health Sciences, University of Bayreuth, Bayreuth 95444, Germany
| | - Eckhard Nagel
- Institute for Medical Management and Health Sciences, University of Bayreuth, Bayreuth 95444, Germany
| | - Volker Ulrich
- Chair of Public Finance, University of Bayreuth, VWL III, Bayreuth 95447, Germany
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Beauvais B, Dolezel D, Ramamonjiarivelo Z. An Exploratory Analysis of the Association between Hospital Quality Measures and Financial Performance. Healthcare (Basel) 2023; 11:2758. [PMID: 37893832 PMCID: PMC10606508 DOI: 10.3390/healthcare11202758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Hospitals are perpetually challenged by concurrently improving the quality of healthcare and maintaining financial solvency. Both issues are among the top concerns for hospital executives across the United States, yet some have questioned if the efforts to enhance quality are financially sustainable. Thus, the aim of this study is to examine if efforts to improve quality in the hospital setting have a corresponding association with hospital profitability. Recent and directly relevant research on this topic is very limited, leaving practitioners uncertain about the wisdom of their investments in interventions which enhance quality and patient safety. We assessed if eight different quality measures were associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Using multivariate regression, we found that improving quality was significantly associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Significant findings were reported for seven of eight quality measures tested, including the HCAHPS Summary Star Rating (p < 0.001), Hospital Compare Overall Rating (p < 0.001), All-Cause Hospital-Wide Readmission Rate (p < 0.01), Total Performance Score (p < 0.001), Safety Domain Score (p < 0.01), Person and Community Engagement Domain Score (p < 0.001), and the Efficiency and Cost Reduction Score (p < 0.001). Failing to address quality and patient safety issues is costly for US hospitals. We believe our findings support the premise that increased attention to the quality of care delivered as well as patients' perceptions of care may allow hospitals to accentuate profitability and advance a hospital's financial position.
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Affiliation(s)
- Brad Beauvais
- School of Health Administration, Texas State University, Encino Hall, Room 250A, 601 University Drive, San Marcos, TX 78666, USA;
| | - Diane Dolezel
- Health Informatics & Information Management Department, Texas State University, Round Rock, TX 78665, USA;
| | - Zo Ramamonjiarivelo
- School of Health Administration, Texas State University, Encino Hall, Room 250A, 601 University Drive, San Marcos, TX 78666, USA;
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Wadhera RK. Value-Based Payment for Cardiovascular Care: Getting to the Heart of the Matter. Circulation 2023; 148:1084-1086. [PMID: 37782698 PMCID: PMC10593505 DOI: 10.1161/circulationaha.123.065661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Rishi K. Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Lu JFR, Chen YI, Eggleston K, Chen CH, Chen B. Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:717-733. [PMID: 35995886 DOI: 10.1007/s10198-022-01504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/26/2022] [Indexed: 05/20/2023]
Abstract
Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.
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Affiliation(s)
- Jui-Fen Rachel Lu
- Graduate Institute of Business and Management and Department of Health Care Management, College of Management, Chang Gung University, Taoyuan City, Taiwan
- Department of Radiation Oncology, Chang Gung Memorial Hospital in Linkou, Taoyuan City, Taiwan
| | - Ying Isabel Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Karen Eggleston
- Shorenstein Asia-Pacific Research Center, Freeman Spogli Institute for International Studies, Stanford University, and NBER, Stanford, CA, USA
| | - Chih-Hung Chen
- Division of Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Brian Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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Hamadi HY, Martinez D, Xu J, Silvera GA, Mallea JM, Hamadi W, Li X, Li Y, Zhao M. Effects of post-discharge telemonitoring on 30-day chronic obstructive pulmonary disease readmissions and mortality. J Telemed Telecare 2023; 29:117-125. [PMID: 33176540 DOI: 10.1177/1357633x20970402] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Much attention has been focused on decreasing chronic obstructive pulmonary disease (COPD) hospital readmissions. The US health system has struggled to meet this goal. The objective of this study was to assess the efficacy of telehealth services on the reduction of hospital readmission and mortality rates for COPD. METHODS We used a cross-sectional design to examine the association between hospital risk-adjusted readmission and mortality rates for COPD and hospital use of post-discharge telemonitoring (TM). Data for 777 hospitals were sourced from the Centers for Medicare & Medicaid Services and the American Hospital Association annual surveys. Propensity score matching using the kennel weights method was applied to calculate the weighted probability of being a hospital that offers post-discharge TM services. RESULTS Hospitals with post-discharge TM had about 34% significantly higher odds (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) 1.06-1.70) of 30-day COPD readmission and 33% significantly lower odds (AOR = 0.67; 95% CI 0.50-0.90) of 30-day COPD mortality compared to hospitals without post-discharge TM services. DISCUSSION Overall, hospitals that offer post-discharge TM services have seen an improvement in 30-day COPD mortality rates. However, those same hospitals have also experienced a significant increase in 30-day COPD readmissions. TM can potentially decrease mortality in patients recently admitted for acute exacerbation of COPD. The results provide further evidence that readmissions present a problematic assessment of health-care quality, as the need for readmission may or may not be directly related to the quality of care received while in hospital.
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Affiliation(s)
- Hanadi Y Hamadi
- Department of Health Administration, Brooks College of Health, University of North Florida, USA
| | - Dayana Martinez
- Department of Health Administration, Brooks College of Health, University of North Florida, USA
| | - Jing Xu
- Department of Health Administration, Brooks College of Health, University of North Florida, USA
| | - Geoffrey A Silvera
- Health Administration, Department of Political Science, Auburn University, USA
| | - Jorge M Mallea
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, USA
| | - Walaa Hamadi
- Department of Internal Medicine, University of Utah, USA
| | - Xinmei Li
- Department of Health Administration, College of Public Health, Fujian Medical University, PR China
| | - Yueping Li
- Fujian Medical Reform and Development Research Centre, Fujian Medical University, PR China
| | - Mei Zhao
- Department of Health Administration, Brooks College of Health, University of North Florida, USA
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Liu L, Nai W, Yang Z. Measuring the State Dependence Effect in Hospital Payment Adjustment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14110. [PMID: 36360987 PMCID: PMC9655927 DOI: 10.3390/ijerph192114110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
Since FY 2013, as a part of the Affordable Care Act (ACA) program, the Hospital Value-Based Purchasing (HVBP) program has adjusted Medicare's payments to hospitals based on the total performance score of the hospital. First, the program reduces a portion of the hospital's Medicare payments in a specific fiscal year, and then, by the end of the same fiscal year, the amount of the payment reductions will be awarded to the hospitals based on the total performance score; thus, the hospitals that do not receive the reward will lose the portion of money reduced by Medicare. In this research, we apply the theory of state dependence and use the dynamic random effect probit model to estimate this effect. The results show that the hospital payment adjustment dynamics have a very significant state dependence effect (0.341); this means that hospitals that received a reward in the previous year are 34.1% more likely to receive a reward this year than the ones that received a penalty in the previous year. Meanwhile, we also find that the state dependence effect varies significantly across hospitals with different ownership (proprietary/government owned/voluntary nonprofit), and the results show that voluntary nonprofit hospitals exhibit the largest effect of state dependence (0.370), while government-owned hospitals exhibit the lowest effect of state dependence (0.293), and proprietary hospitals are in the middle. Among the factors that influence the likelihood that a hospital receives a reward, we find that teaching hospitals with a large number of beds (>400) are less likely be rewarded; in terms of ownership, we find that voluntary nonprofit hospitals are more likely be rewarded; in terms of demographic factors, hospitals where the average household income are higher within the region are more likely be rewarded.
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Affiliation(s)
- Lu Liu
- School of Business, St. Bonaventure University, St. Bonaventure, NY 14778, USA
| | - Wei Nai
- School of Electronic Information, Huzhou College, Huzhou 313000, China
| | - Zan Yang
- Public Teaching and Research Department, Huzhou College, Huzhou 313000, China
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Chen HC, Cates T, Taylor M. The effect of patient quality measurements and HCAHPS patient satisfaction on hospital reimbursements. HUMAN SYSTEMS MANAGEMENT 2022. [DOI: 10.3233/hsm-220042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The Centers of Medicare & Medicaid Services (CMS) links hospital reimbursements to quality metrics. Likewise, the Hospital Value-Based Purchasing (VBP) program offers financial incentives to acute-care hospitals based on performance improvements on several quality measures included in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. A research gap exists with regard to assessing the effectiveness of VBP incentives on improving the patient’s quality of care. OBJECTIVE: This study is to determine whether hospitals which reported better patient quality metrics and lower frequency of pressure sores received higher reimbursements. METHODS: The data were retrieved from the CMS Care Compare website utilizing matched data from 2297 US hospitals. Information on HCAHPS, the VBP Program in Patient Safety Index, and Reimbursements was obtained for this study. Partial Least Square (PLS) was utilized thru SmartPLS 3.0 to test the hypotheses. RESULTS: The results did not reveal any financial penalties when hospitals reported lower patient quality outcomes and increased numbers of pressure sores. However, lower patient quality measures were associated with lower patient satisfaction. Controversially, lower patient satisfaction scores were associated with higher reimbursement rates overall. CONCLUSIONS: The main contribution of this study reveals that the effectiveness of value-based reimbursements and the concept of continuous improvement is constrained due to the lack of unified measurement objectives across US healthcare institutions.
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Affiliation(s)
- Hui-Chuan Chen
- College of Business and Global Affairs, University of Tennessee at Martin, Martin, TN, USA
| | - Tommy Cates
- College of Business and Global Affairs, University of Tennessee at Martin, Martin, TN, USA
| | - Monty Taylor
- College of Business and Global Affairs, University of Tennessee at Martin, Martin, TN, USA
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Pozniak A, Lammers E, Mukhopadhyay P, Cogan C, Ding Z, Goyat R, Hanslits K, Ji N, Jin Y, Repeck K, Schrager J, Young E, Turenne M. Association of the Home Health Value-Based Purchasing Model With Quality, Utilization, and Medicare Payments After the First 5 Years. JAMA HEALTH FORUM 2022; 3:e222723. [PMID: 36218946 PMCID: PMC9508657 DOI: 10.1001/jamahealthforum.2022.2723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Question How did quality, utilization, and Medicare payments differ after the 5 years of the Home Health Value-Based Purchasing (HHVBP) model? Findings In this cohort study of US patients who received care at a home health agency between 2013 and 2020 in 9 original HHVBP states compared with those in comparison states, a difference-in-differences analysis found the HHVBP model was associated with lower Medicare payments that were associated with lower utilization of inpatient and skilled nursing facility services. Quality was better or similar. Meaning The study results suggest that financial incentives for home health agency quality performance were associated with reduced Medicare payments and utilization while improving or maintaining quality. Importance The original Home Health Value-Based Purchasing (HHVBP) model provided financial incentives to home health agencies for quality improvement in 9 randomly selected US states. Objective To evaluate quality, utilization, and Medicare payments for home health patients in HHVBP states compared with those in comparison states. Design, Setting, and Participants This cohort study was conducted in 2021 with secondary data from January 2013 to December 2020. A difference-in-differences design and multivariate linear regression were used to compare outcomes for Medicare and Medicaid beneficiaries who received home health care in HHVBP states with those in 41 comparison states during 3 years of preintervention (2013-2015) and the subsequent 5 years (2016-2020). Exposures Home health care provided by a home health agency in HHVBP states and comparison states. Main Outcomes and Measures Utilization (unplanned hospitalizations, emergency department visits, skilled nursing facility [SNF] visits) for Medicare beneficiaries within 60 days of beginning home health, Medicare payments during and 37 days after home health episodes, and quality of care (functional status, patient experience) during home health episodes. Results Among 34 058 796 home health episodes (16 584 870 beneficiaries; mean [SD] age of 76.6 [11.7] years; 60.5% female; 11.2% Black non-Hispanic; 79.5% White non-Hispanic) from January 2016 to December 2020, 22.6% were in HHVBP states and 77.4% were in non-HHVBP states. For the HHVBP and non-HHVBP groups, 60.4% and 61.0% of episodes were provided to female patients; 10.0% and 13.6% were provided to Black non-Hispanic patients, and 82.4% and 75.2% were provided to White non-Hispanic patients, respectively. Unplanned hospitalizations decreased by 0.15 percentage points (95% CI, –0.30 to –0.01) more in HHVBP states, a 1.0% decline compared with 15.7% at baseline. The use of SNFs decreased by 0.34 percentage points (95% CI, –0.40 to –0.27) more in HHVBP states, a 6.9% decline compared with the 4.9% baseline average. There was an association between HHVBP and a reduction in average Medicare payments per day of $2.17 (95% CI, –$3.67 to –$0.68) in HHVBP states, primarily associated with reduced inpatient and SNF services, which corresponded to an average annual Medicare savings of $190 million. There was greater functional improvement in HHVBP states than comparison states and no statistically significant change in emergency department use or most measures of patient experience. Conclusions and Relevance In this cohort study, the HHVBP model was associated with lower Medicare payments that were associated with lower utilization of inpatient and SNF services, with better or similar quality of care.
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Affiliation(s)
- Alyssa Pozniak
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Eric Lammers
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Chad Cogan
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Zhechen Ding
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Rashmi Goyat
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Nan Ji
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Yan Jin
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Kaitlyn Repeck
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Eric Young
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Li J. Value-Based Payments in Health Care: Evidence from a Nationwide Randomized Experiment in the Home Health Sector. JOURNAL OF POLICY ANALYSIS AND MANAGEMENT : [THE JOURNAL OF THE ASSOCIATION FOR PUBLIC POLICY ANALYSIS AND MANAGEMENT] 2022; 41:1090-1117. [PMID: 37881443 PMCID: PMC10598776 DOI: 10.1002/pam.22415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
Value-based payment programs, also known as pay-for-performance, use financial incentives to motivate providers to invest in quality and are a critical part of Medicare health care reform. This study examines the first year of the Home Health Value-Based Purchasing program, a nationally representative cluster randomized experiment implemented by the Centers for Medicare & Medicaid Services in 2016. The goal of the program is to achieve better home health care quality. Home health agencies in treatment states were rewarded or penalized based on their performance on agency-reported and non-agency-reported quality measures. The program improved agency-reported measures by approximately one percentage point, and performance gains suggest a dose-response relationship with respect to incentive size. However, the performance gains in agency-reported measures did not reflect true quality improvement. I find evidence that agencies manipulated their coding of patients and inflated their performance. Coding manipulation explains the entirety of the program's impact on agency-reported measures.
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Affiliation(s)
- Jun Li
- Department of Public Administration and International Affairs, Maxwell School of Citizenship and Public Affairs, Syracuse University, 314 Lyman Hall, Syracuse, New York 13244
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Weinmeyer RM, McHugh M, Coates E, Bassett S, O'Dwyer LC. Employer-Led Strategies to Improve the Value of Health Spending: A Systematic Review. J Occup Environ Med 2022; 64:218-225. [PMID: 35244086 PMCID: PMC8887846 DOI: 10.1097/jom.0000000000002395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality. METHODS We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes. RESULTS Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising. CONCLUSIONS More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.
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Affiliation(s)
- Richard M Weinmeyer
- Northwestern University, Chicago, Illinois (Dr Weinmeyer, Dr McHugh, Dr Basset, and Ms O'Dwyer); UnitedHealth Group, Minneapolis, Minnesota (Ms Coates)
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Ramirez AG, Marsh KM, McMurry TL, Turrentine FE, Tracci MA, Jones RS. How Total Performance Scores of Medicare Value-Based Purchasing Program Hospitals Change Over Time. J Healthc Qual 2022; 44:78-87. [PMID: 34469925 DOI: 10.1097/jhq.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type. METHODS Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types. RESULTS Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations. CONCLUSION In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores. IMPLICATIONS Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.
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Glance LG, Nerenz DR, Joynt Maddox KE, Hall BL, Dick AW. Reproducibility of Hospital Rankings Based on Centers for Medicare & Medicaid Services Hospital Compare Measures as a Function of Measure Reliability. JAMA Netw Open 2021; 4:e2137647. [PMID: 34874402 PMCID: PMC8652605 DOI: 10.1001/jamanetworkopen.2021.37647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Unreliable performance measures can mask poor-quality care and distort financial incentives in value-based purchasing. OBJECTIVE To examine the association between test-retest reliability and the reproducibility of hospital rankings. DESIGN, SETTING, AND PARTICIPANTS In a cross-sectional design, Centers for Medicare & Medicaid Services Hospital Compare data were analyzed for the 2017 (based on 2014-2017 data) and 2018 (based on 2015-2018 data) reporting periods. The study was conducted from December 13, 2020, to September 30, 2021. This analysis was based on 28 measures, including mortality (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), readmissions (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), and surgical complications (postoperative acute kidney failure, postoperative respiratory failure, postoperative sepsis, and failure to rescue). EXPOSURES Measure reliability based on test-retest reliability testing. MAIN OUTCOMES AND MEASURES The reproducibility of hospital rankings was quantified by calculating the reclassification rate across the 2017 and 2018 reporting periods after categorizing the hospitals into terciles, quartiles, deciles, and statistical outliers. Linear regression analysis was used to examine the association between the reclassification rate and the intraclass correlation coefficient for each of the classification systems. RESULTS The analytic cohort consisted of 28 measures from 4452 hospitals with a median of 2927 (IQR, 2378-3160) hospitals contributing data for each measure. The hospitals participating in the Inpatient Prospective Payment System (n = 3195) had a median bed size of 141 (IQR, 69-261), average daily census of 70 (IQR, 24-155) patients, and a median disproportionate share hospital percentage of 38.2% (IQR, 18.7%-36.6%). The median intraclass correlation coefficient was 0.78 (IQR, 0.72-0.81), ranging between 0.50 and 0.85. The median reclassification rate was 70% (IQR, 62%-71%) when hospitals were ranked by deciles, 43% (IQR, 39%-45%) when ranked by quartiles, 34% (IQR, 31%-36%) when ranked by terciles, and 3.8% (IQR, 2.0%-6.2%) when ranked by outlier status. Increases in measure reliability were not associated with decreases in the reclassification rate. Each 0.1-point increase in the intraclass correlation coefficient was associated with a 6.80 (95% CI, 2.28-11.30; P = .005) percentage-point increase in the reclassification rate when hospitals were ranked into performance deciles, 4.15 (95% CI, 1.16-7.14; P = .008) when ranked into performance quartiles, 1.47 (95% CI, 1.84, 4.77; P = .37) when ranked into performance terciles, and 3.70 (95% CI, 1.30-6.09; P = .004) when ranked by outlier status. CONCLUSIONS AND RELEVANCE In this study, more reliable measures were not associated with lower rates of reclassifying hospitals using test-retest reliability testing. These findings suggest that measure reliability should not be assessed with test-retest reliability testing.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - David R. Nerenz
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Bruce L. Hall
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
- Olin Business School, Washington University in St Louis, St Louis, Missouri
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
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Altalib H, McMillan KK, Padilla S, Pugh MJ. Epilepsy quality performance in a national sample of neurologists and primary care providers: Characterizing trends in acute and chronic care management. Epilepsy Behav 2021; 123:108218. [PMID: 34479039 DOI: 10.1016/j.yebeh.2021.108218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/22/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Epilepsy-specific quality indicators and performance measures have been published and revised multiple times. The application of epilepsy-specific quality measures has been demonstrated in a few healthcare systems. However, there is no information to date on changes in epilepsy performance measures over time, and across settings, in a national sample. The Department of Veterans Affairs (VA) healthcare system provides an opportunity to study the changes in epilepsy-specific performance over time, in acute versus chronic epilepsy care, as well as in primary versus specialty care. METHODS Chart extractions of newly diagnosed epilepsy and chronic care of Veterans with epilepsy within the VA system were performed. Veterans with ICD-9-CM diagnosis 345.XX and 780.39 from 2007-2014 were identified. Epilepsy-specific performance measures based on the Quality Indicators in Epilepsy Treatment (QUIET) VA measurement were ascertained for each Veteran with epilepsy. Difference in care across time (2009, 2012, and 2014), source of epilepsy care (primary care only, neurology only, and shared care between neurology and primary care) was analyzed. Differences in proportion of care measures across variables were compared using chi-square statistics. RESULTS Chart reviews of 2386 Veterans with epilepsy included 297 women (11.2%), 281 (10.5%) receiving acute care and 2105 (89.5%) receiving chronic care. Across all years 203 (72.5%) had electroencephalograph ordered/performed, 225 (80.4%) had neuroimaging ordered/performed, 106 (37.9%) were instructed about driving precautions, 71 (25.4%) were educated about safety and injury prevention, and 251 (89.6%) had anti-seizure medication monotherapy initiated. The proportion of people with new-onset seizures educated about diagnosis and type of seizure increased over time 30 (34.9%) in 2008, 42 (43.8%) in 2012, and 52 (53.1%). Of the 2105 Veterans receiving chronic care 864 (41.1%) encounters documented compliance of anti-seizure medication, 361 (17.15%) encounters addressed driving restrictions, 1345 (63.9%) encounters documented general education and counseling, 250 (11.9%) of encounters documented safety and injury prevention, 488 (23.2%) of encounters documented medication side effects, and 463 (22.0%) of encounters documented discussion of treatment options. With chronic epilepsy care, documentation of quality measures did not change with time. Veterans who were co-managed by primary care and neurology had a higher proportion of driving instruction and safety instructions compared to neurology or primary care alone. DISCUSSION In general, the epilepsy performance measures were high (>70% of new-onset epilepsy) for documentation diagnostic procedures (such as EEG and neuroimaging) and low across key educational and counseling measures (<50%). Despite the emphasis on the importance of psychosocial education and holistic management in the academic literature, through advocacy work, and during professional meetings, there was not a significant improvement in education and counseling over time. Some aspects of psychosocial education were performed better among primary care providers compared to neurologists. However, more attention and work need to be dedicated on implementing and documenting education and counseling people with epilepsy in the clinical setting.
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Affiliation(s)
- Hamada Altalib
- Connecticut VA Healthcare System, Yale School of Medicine, USA.
| | - Katharine K McMillan
- Department of Epidemiology and Biostatistics, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA; Behavioral Scientist, PO Box 713, Comfort, TX 78013, USA.
| | - Silvia Padilla
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Mary Jo Pugh
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Arntson E, Dimick JB, Nuliyalu U, Errickson J, Engler TA, Ryan AM. Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program. Ann Surg 2021; 274:e301-e307. [PMID: 34506324 DOI: 10.1097/sla.0000000000003641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING Fee-for-service Medicare 2009-2015. PARTICIPANTS Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.
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Affiliation(s)
- Emily Arntson
- University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Justin B Dimick
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Josh Errickson
- University of Michigan Consulting for Statistics, Computing and Analytics Research, Ann Arbor, Michigan
| | - Tedi A Engler
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Andrew M Ryan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
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Discussion: The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery. Plast Reconstr Surg 2021; 147:154e-155e. [PMID: 33370074 DOI: 10.1097/prs.0000000000007500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Donzelli A. The De-adoption of Low-Value Health Care. JAMA 2021; 325:887-888. [PMID: 33651084 DOI: 10.1001/jama.2020.25515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alberto Donzelli
- Scientific Committee, Foundation Allineare Sanità e Salute, Milan, Italy
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Wadhera RK, Vaduganathan M, Jiang GY, Song Y, Xu J, Shen C, Bhatt DL, Yeh RW, Fonarow GC. Performance in Federal Value-Based Programs of Hospitals Recognized by the American Heart Association and American College of Cardiology for High-Quality Heart Failure and Acute Myocardial Infarction Care. JAMA Cardiol 2021; 5:515-521. [PMID: 32074242 DOI: 10.1001/jamacardio.2020.0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Importance The US Centers for Medicare & Medicaid Services have implemented national value-based programs that incentivize hospitals to deliver better cardiovascular care. However, it is unclear how hospitals recognized for high-quality cardiovascular care by American Heart Association (AHA) and American College of Cardiology (ACC) national quality improvement initiatives (termed award hospitals) have performed under value-based programs. Objective To determine if hospitals that received awards for high-quality cardiovascular care from the AHA/ACC were less likely to be penalized under the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based Purchasing Program (VBP) compared with other hospitals. Design, Setting, and Participants This national cross-sectional study included data from short-term acute care hospitals in the United States that were participating in the HRRP or VBP in fiscal year 2018. Exposures Recognition awards for high-quality care from the AHA's Get With The Guidelines-Heart Failure and ACC's Chest Pain-MI (myocardial infarction) Registry national quality improvement initiatives. Main Outcomes and Measures Proportion of hospitals that received a financial penalty or financial reward under the HRRP or VBP, median payment adjustments, and hospital-level 30-day mortality rates. Results This study included 3175 hospitals participating in the HRRP and 2781 hospitals participating in the VBP in fiscal year 2018. Under the HRRP, a higher proportion of award hospitals received financial penalties compared with other hospitals (419 [85.5%] vs 2112 [78.7%]; P < .001), although payment reductions were similar (median, 0.39% [interquartile range (IQR), 0.08%-0.84%] vs 0.33% [IQR, 0.03%-0.89%]; P = .17). Under the VBP, a higher proportion of award hospitals received penalties compared with other hospitals (250 [51.7%] vs 950 [41.4%]; P < .001), and fewer award hospitals received financial rewards (234 [48.4%] vs 1347 [58.6%]; P < .001). Median payment reductions were higher for award hospitals than other hospitals (0.01% [IQR, 0.00%-0.38%] vs 0.0% [IQR, 0.00%-0.28%]; P < .001), and median payment increases were lower (0.0% [IQR, 0.00%-0.34%] vs 0.13% [IQR, 0.00%-0.60%]; P < .001). Thirty-day mortality at award hospitals was similar (acute myocardial infarction, 13.2% vs 13.2%; P = .76) or slightly lower (heart failure, 11.3% vs 11.7%; P = .001) compared with other hospitals. Conclusions and Relevance Hospitals that received awards for high-quality cardiovascular care from the AHA/ACC were more likely to be penalized and less likely to be financially rewarded by federal value-based programs. These findings highlight the potential need to standardize measurement of cardiovascular care quality.
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Affiliation(s)
- Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Ginger Y Jiang
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Yang Song
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Gregg C Fonarow
- David Geffen School of Medicine, Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles.,Associate Editor for Health Care Quality and Guidelines
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Revere L, Langland-Orban B, Large J, Yang Y. Evaluating the robustness of the CMS Hospital Value-Based Purchasing measurement system. Health Serv Res 2021; 56:464-473. [PMID: 33393668 DOI: 10.1111/1475-6773.13608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The Hospital Value-Based Purchasing Program (HVBP) is a pay for performance system that impacts traditional Medicare fee-for-service payments to hospitals through rewards and penalties. OBJECTIVES To explore variation in overall and individual-hospital total performance score (TPS) and embedded domains for hospitals during 2014-2018. DATA SOURCE Hospital data were retrieved from the publicly available HOSArchive dataset. STUDY DESIGN Distribution of annual TPS and HVBP domain scores for 2014-2018 was evaluated using descriptive statistics. Transitional probabilities were analyzed to evaluate annual movement in the TPS ranking for outlier hospitals in the Top and Bottom 5%. PRINCIPAL FINDINGS TPS scores are positively skewed while the distribution of domain scores vary with patient experience, (clinical) outcome, and efficiency domains having a large number of (positive) outliers. Mean TPS score decreased from 40.54 in 2014 to 38.04 by 2018. Improvement was shown in mean domain scores for clinical process of care and clinical outcome using 95% confidence intervals, with hospitals gaining 10 points over the study period in clinical outcome. Changes in the mean scores for other domains did not show consistent increases or decreases. Chi-square analyses of hospital ranking categories showed some evidence that, as a group, hospitals initially ranked in the Bottom 5% are making consistent annual movements to higher categories. In contrast, over half of the hospitals ranking in the initial Top 5% remained in the top category across all study years. CONCLUSIONS It may be time for CMS to redesign the HVBP incentive program to assure the measures accurately demonstrate sustained improvement, the domain weights appropriately reflect the level of importance, and the TPS comparative ranking methodology does not discourage lower-performing hospitals from actively improving the care they deliver and achieving top ranks.
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Affiliation(s)
- Lee Revere
- University of Texas School of Public Health, Houston, Texas, USA
| | | | - John Large
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Yijiong Yang
- University of Texas School of Public Health, Houston, Texas, USA
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Hamadi HY, Martinez D, Palenzuela J, Spaulding AC. Magnet Hospitals and 30-Day Readmission and Mortality Rates for Medicare Beneficiaries. Med Care 2021; 59:6-12. [PMID: 32925454 DOI: 10.1097/mlr.0000000000001427] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND US hospitals are penalized for excess 30-day readmissions and mortality for select conditions. Under the Centers for Medicare and Medicaid Services policy, readmission prevention is incentivized to a greater extent than mortality reduction. A strategy to potentially improve hospital performance on either measure is by improving nursing care, as nurses provide the largest amount of direct patient care. However, little is known as to whether achieving nursing excellence, such as Magnet status, is associated with improved hospital performance on readmissions and mortality. OBJECTIVE The purpose of this study was to examine the relationship between hospitals' Magnet status and performance on readmission and mortality rates for Medicare beneficiaries. RESEARCH DESIGN This is a cross-sectional analysis of Medicare readmissions and mortality reduction programs from 2013 to 2016. A propensity score-matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. SUBJECTS The sample was comprised of 3877 hospitals. MEASURES The outcome measures were 30-day risk-standardized readmission and mortality rates. RESULTS Following propensity score matching on hospital characteristics, we found that Magnet hospitals outperformed non-Magnet hospitals in reducing mortality; however, Magnet hospitals performed worse in reducing readmissions for acute myocardial infarction, coronary artery bypass grafting, and stroke. CONCLUSIONS Magnet hospitals performed better on the Hospital Value-Based Purchasing Mortality Program than the Hospital Readmissions Reduction Program. The results of this study suggest the need for The Magnet Recognition Program to examine the role of nurses in postdischarge activities as a component of its evaluation criteria.
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Affiliation(s)
- Hanadi Y Hamadi
- Department of Health Administration, Brooks College of Health, University of North Florida
| | - Dayana Martinez
- Department of Health Administration, Brooks College of Health, University of North Florida
| | - Julia Palenzuela
- Department of Health Administration, Brooks College of Health, University of North Florida
| | - Aaron C Spaulding
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic Robert D. and Patricia E. Kern, Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
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Abstract
EXECUTIVE SUMMARY Quality improvement, regulatory, and payer organizations use various definitions of hospital mortality as clinical outcome measures. In this prospective study, the authors evaluated a multicomponent intervention aimed at reducing inpatient mortality in a multistate healthcare delivery system. The project was initiated because of a statistically nonsignificant upward trend in mortality suggested by a six-quarter rise in the observed/expected mortality ratio generated by the Vizient Clinical Data Base and Resource Manager. The design of the mortality reduction plan was influenced by the known limitations of using hospital-wide mortality as a quality improvement measure. The primary objective was to reduce mortality through focused care redesign. The project leadership team attempted to implement standardized system-wide improvements while allowing individual hospitals to simultaneously pursue site-specific practice redesign opportunities. Between Q3, 2015, and Q4, 2017, system-wide mortality reduced from 1.78 to 1.53 (per 100 admissions; p = .01). The actual plan implemented in Mayo Clinic's hospitals is included as Appendix A to this article, published online as Supplemental Digital Content. The authors included it to allow comparison with similar efforts at other healthcare systems, as well as to stimulate criticism and discussion by readers.
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Husaini M, Joynt Maddox KE. Paying for Performance Improvement in Quality and Outcomes of Cardiovascular Care: Challenges and Prospects. Methodist Debakey Cardiovasc J 2020; 16:225-231. [PMID: 33133359 DOI: 10.14797/mdcj-16-3-225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with pay-for-performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so.
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Affiliation(s)
- Mustafa Husaini
- WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MISSOURI
| | - Karen E Joynt Maddox
- WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MISSOURI.,INSTITUTE FOR PUBLIC HEALTH AT WASHINGTON UNIVERSITY, ST. LOUIS, MISSOURI
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Staloff JA, Navathe AS, Liao JM. It’s Time to Advance Payment Reform Using the Principle of Policy Equipoise. JAMA HEALTH FORUM 2020; 1:e201323. [DOI: 10.1001/jamahealthforum.2020.1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jonathan A. Staloff
- Department of Family Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania
| | - Joshua M. Liao
- Department of Family Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
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Nishizaki Y, Ueda R, Shinozaki T, Tokuda Y. Hospital characteristics preferred by medical students for their residency programs: A nationwide matching data analysis. J Gen Fam Med 2020; 21:242-247. [PMID: 33304718 PMCID: PMC7689235 DOI: 10.1002/jgf2.370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/10/2020] [Accepted: 08/03/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In 2004, Japan introduced a mandatory 2-year postgraduate training program for graduating medical students with a super-rotation curriculum. A national matching system was established to determine the hospital residency programs best suited for the students. We examined the hospital characteristics preferred by applicants for residencies. METHODS A nationwide cross-sectional study was conducted. Data on salaries, bonuses, and number of accepted ambulances were compiled from the Residency Electronic Information System. Information on the prefectural population, urban area, and number of senior residents (postgraduate years 3-5) for specialty training was extracted from data published on the web page. The ratio of the number of first-choice applicants to recruitment capacity (matching ratio) for each program was compared between the characteristics of the hospitals and prefectures. RESULTS A strong linear relationship was observed between the number of first-choice applications and the allocated number of resident positions (correlation coefficient, .72). The matching ratio was greater in community hospitals (2.10 times compared with university hospitals; 95% confidence interval [CI], 1.75-2.53), in hospitals with higher numbers of accepted ambulance cases (1.05 times per 1000 annually; 95% CI, 1.03-1.08), and in hospitals that served a larger prefectural population (1.05 times per million; 95% CI, 1.02-1.08). CONCLUSIONS Financial incentives do not seem to attract residency applicants. Applicants prefer non-university hospitals located in populous areas and those that accept larger number of ambulance cases. To recruit junior residents, an emergency department may need to have higher activity with larger numbers and variety of cases.
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Affiliation(s)
- Yuji Nishizaki
- Medical Technology Innovation CenterJuntendo UniversityTokyoJapan
- Department of Cardiovascular Biology and MedicineJuntendo University Graduate School of MedicineTokyoJapan
| | - Rieko Ueda
- Medical Technology Innovation CenterJuntendo UniversityTokyoJapan
- Department of Cardiovascular Biology and MedicineJuntendo University Graduate School of MedicineTokyoJapan
| | - Tomohiro Shinozaki
- Department of Information and Computer TechnologyFaculty of EngineeringTokyo University of ScienceTokyoJapan
| | - Yasuharu Tokuda
- Department of MedicineMuribushi Okinawa for Teaching HospitalsOkinawaJapan
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Nikpay S, Pungarcher I, Frakt A. An Economic Perspective on the Affordable Care Act: Expectations and Reality. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:889-904. [PMID: 32589202 DOI: 10.1215/03616878-8543340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The Affordable Care Act (ACA) was enacted in 2010 to address both high uninsured rates and rising health care spending through insurance expansion reforms and efforts to reduce waste. It was expected to have a variety of impacts in areas within the purview of economics, including effects on health care coverage, access to care, financial security, labor market decisions, health, and health care spending. To varying degrees, legislative, executive, and judicial actions have altered its implementation, affecting the extent to which expectations in each of these dimensions have been realized. We review the ACA's reforms, the subsequent actions that countered them, and the expected and realized effects on coverage, access to care, financial security, health, labor market decisions, and health care spending.
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Does Patient Safety Pay? Evaluating the Association Between Surgical Care Improvement Project Performance and Hospital Profitability. J Healthc Manag 2020; 64:142-154. [PMID: 31999263 DOI: 10.1097/jhm-d-17-00208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
EXECUTIVE SUMMARY Financial issues are top concerns for hospital executives. Evolving reimbursement structures focused on value provide an incentive to fully understand how patient safety performance and financial outcomes are connected. To that end, this study examines the relationships between Surgical Care Improvement Project (SCIP) measurements and hospital financial performance.Using multinomial logistic regression, we determined the association between hospital patient safety performances via analysis of eight prophylaxis data elements drawn from the archived Hospital Compare data. The measures are SCIP-Inf-1 (prophylactic antibiotic prophylaxis received within 1 hr prior to surgical incision), SCIP-Inf-2 (prophylactic antibiotic selection for surgical patients), SCIP-Inf-3 (prophylactic antibiotics discontinued within 24 hr after surgery end time), SCIP-Inf-4 (cardiac surgery patients with controlled 6 A.M. postoperative serum glucose management), SCIP-Inf-9 (urinary catheter removal postsurgery), SCIP-Inf-Card-2 (beta-blocker during the perioperative period), and SCIP-Inf-VTE-2 (venous thromboembolism prophylaxis). Data from the American Hospital Association provided two dimensions of organizational profitability: operating margin and net patient revenue. Our results indicate that improved hospital safety performance is associated with a relative risk of higher operating margin and net patient revenue, with some variation noted among the measures of patient safety. Our findings suggest that targeted improvement in patient safety performance, as evaluated in the Hospital Compare data, is associated with improved financial performance at the hospital level. Increased attention to safe care delivery may allow hospitals to generate additional patent care earnings, improve margins, and create capital to advance hospital financial position.
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Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review. Med Care 2020; 58:734-743. [PMID: 32692140 DOI: 10.1097/mlr.0000000000001354] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.
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Zilberberg MD, Tjia J, Shorr AF. Bang for Your Buck: Could Medicare's Hospital Value-Based Purchasing Program Rein in Health-Care Spending in Pneumonia? Chest 2020; 157:1051-1052. [PMID: 32386623 DOI: 10.1016/j.chest.2019.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/14/2019] [Indexed: 10/24/2022] Open
Affiliation(s)
| | - Jennifer Tjia
- University of Massachusetts School of Medicine, Worcester, MA
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Wadhera RK, Wang Y, Figueroa JF, Dominici F, Yeh RW, Joynt Maddox KE. Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017. JAMA 2020; 323:961-969. [PMID: 32154858 PMCID: PMC7064881 DOI: 10.1001/jama.2020.1021] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries). OBJECTIVE To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018. EXPOSURES Dual vs nondual enrollment status. MAIN OUTCOMES AND MEASURES Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates. RESULTS There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.
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Affiliation(s)
- Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Yun Wang
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Francesca Dominici
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Center for Health Economics and Policy, Institute for Public Health and Cardiovascular Division, School of Medicine, Washington University in St Louis, St Louis, Missouri
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Abstract
INTRODUCTION Hospital Value-Based Purchasing (HVBP) is an initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide. A hospital's trauma certification has the potential to influence HVBP scores as attaining the certification provides indication of the service quality offered by the hospital. As such, this study focuses on hospitals' level of trauma certification attainment through the American College of Surgeons and whether this certification is associated with greater HVBP. METHODS A retrospective review of the 2015 HVBP database, 2015 Area Health Resources Files (AHRF) database, and the 2015 American Hospital Association (AHA) database is utilized, and propensity score matching was employed to determine the association between level of trauma certification and scores on HVBP dimensions. RESULTS Results reveal trauma certification is associated with lower HVBP domain scores when compared to hospitals without trauma certification. In addition, hospitals with a greater degree of trauma specialization were associated with lower total performance score and efficiency domain scores. CONCLUSIONS Although payers attempt to connect hospital reimbursements with quality and outcomes, unintended consequences may occur. In response to these results, HVBP risk adjustment and scoring methods should receive further scrutiny.
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Figueroa JF, Wadhera RK, Jha AK. Eliminating Wasteful Health Care Spending—Is the United States Simply Spinning Its Wheels? JAMA Cardiol 2020; 5:9-10. [DOI: 10.1001/jamacardio.2019.4339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rishi K. Wadhera
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashish K. Jha
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Psotka MA, Fonarow GC, Allen LA, Joynt Maddox KE, Fiuzat M, Heidenreich P, Hernandez AF, Konstam MA, Yancy CW, O'Connor CM. The Hospital Readmissions Reduction Program. JACC-HEART FAILURE 2020; 8:1-11. [DOI: 10.1016/j.jchf.2019.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 07/08/2019] [Accepted: 07/29/2019] [Indexed: 12/19/2022]
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Banerjee S, McCormick D, Paasche-Orlow MK, Lin MY, Hanchate AD. Association between degree of exposure to the Hospital Value Based Purchasing Program and 30-day mortality: experience from the first four years of Medicare's pay-for-performance program. BMC Health Serv Res 2019; 19:921. [PMID: 31791322 PMCID: PMC6889655 DOI: 10.1186/s12913-019-4562-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background The Hospital Value Based Purchasing Program (HVBP) in the United States, announced in 2010 and implemented since 2013 by the Centers for Medicare and Medicaid Services (CMS), introduced payment penalties and bonuses based on hospital performance on patient 30-day mortality and other indicators. Evidence on the impact of this program is limited and reliant on the choice of program-exempt hospitals as controls. As program-exempt hospitals may have systematic differences with program-participating hospitals, in this study we used an alternative approach wherein program-participating hospitals are stratified by their financial exposure to penalty, and examined changes in hospital performance on 30-day mortality between hospitals with high vs. low financial exposure to penalty. Methods Our study examined all hospitals reimbursed through the Medicare Inpatient Prospective Payment System (IPPS) – which include most community and tertiary acute care hospitals – from 2009 to 2016. A hospital’s financial exposure to HVBP penalties was measured by the share of its annual aggregate inpatient days provided to Medicare patients (“Medicare bed share”). The main outcome measures were annual hospital-level 30-day risk-adjusted mortality rates for acute myocardial infarction (AMI), heart failure (HF) and pneumonia patients. Using difference-in-differences models we estimated the change in the outcomes in high vs. low Medicare bed share hospitals following HVBP. Results In the study cohort of 1902 US hospitals, average Medicare bed share was 61 and 41% in high (n = 540) and low (n = 1362) Medicare bed share hospitals, respectively. High Medicare bed share hospitals were more likely to have smaller bed size and less likely to be teaching hospitals, but ownership type was similar among both Medicare bed share groups.. Among low Medicare bed share (control) hospitals, baseline (pre-HVBP) 30-day mortality was 16.0% (AMI), 10.9% (HF) and 11.4% (pneumonia). In both high and low Medicare bed share hospitals 30-day mortality experienced a secular decrease for AMI, increase for HF and pneumonia; differences in the pre-post change between the two hospital groups were small (< 0.12%) and not significant across all three conditions. Conclusions HVBP was not associated with a meaningful change in 30-day mortality across hospitals with differential exposure to the program penalty.
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Affiliation(s)
- Souvik Banerjee
- Disparities Research Unit and The Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Danny McCormick
- Harvard Medical School, Boston, USA.,Cambridge Health Alliance, Cambridge, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Ave #2092, Boston, MA, 02118, USA
| | - Meng-Yun Lin
- Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Ave #2092, Boston, MA, 02118, USA
| | - Amresh D Hanchate
- Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Ave #2092, Boston, MA, 02118, USA. .,VA Boston Healthcare System, Boston, MA, USA.
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Metcalfe D, Zogg CK, Judge A, Perry DC, Gabbe B, Willett K, Costa ML. Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland. Bone Joint J 2019; 101-B:1015-1023. [PMID: 31362544 PMCID: PMC6683232 DOI: 10.1302/0301-620x.101b8.bjj-2019-0173.r1] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Aims Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. Materials and Methods We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. Results There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. Conclusion This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015–1023.
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Affiliation(s)
- D Metcalfe
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - C K Zogg
- Yale School of Medicine, New Haven, Connecticut, USA
| | - A Judge
- Centre for Statistics in Medicine, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol NHS Foundation Trust, University of Bristol, Southmead Hospital, Bristol, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - D C Perry
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - B Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - K Willett
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - M L Costa
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
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Wolfe JD, Joynt Maddox KE. Heart Failure and the Affordable Care Act: Past, Present, and Future. JACC-HEART FAILURE 2019; 7:737-745. [PMID: 31401094 DOI: 10.1016/j.jchf.2019.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 01/14/2023]
Abstract
The Affordable Care Act (ACA) and other major health care legislative acts have had an important impact on the care of heart failure patients in the United States. The main effects of the ACA include regulation of the health insurance industry, expansion of access to health care, and health care delivery system reform, which included the creation of several alternative payment models. Particular components of the ACA, such as the elimination of annual and lifetime caps on spending, Medicaid expansion, and the individual and employer mandate, could have positive effects for heart failure patients. However, the benefits of value-based and alternative payment models such as the Hospital Readmissions Reduction Program and bundled payment programs for heart failure outcomes are less clear, and controversy exists regarding whether some of these programs may even worsen outcomes. As the population ages and the prevalence of heart failure continues to rise, this syndrome will likely remain a key clinical focus for policymakers. Therefore, heart failure clinicians should be aware of how legislation affects clinical practice and be prepared to adapt to continued changes in health policy.
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Affiliation(s)
- Jonathan D Wolfe
- Cardiology Division, Washington University School of Medicine, St. Louis, Missouri
| | - Karen E Joynt Maddox
- Cardiology Division, Washington University School of Medicine, St. Louis, Missouri.
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Abstract
BACKGROUND Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care. OBJECTIVES Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic. SELECTION CRITERIA We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms. DATA COLLECTION AND ANALYSIS Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables. MAIN RESULTS We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance. AUTHORS' CONCLUSIONS It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.
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Affiliation(s)
- Tim Mathes
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Dawid Pieper
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Johannes Morche
- Federal Joint CommitteeMedical Consultancy DepartmentWegelystraße 8BerlinGermany
| | - Stephanie Polus
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
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Kotwal S, Abougergi MS, Wright S. Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study. Int J Qual Health Care 2019; 31:378-384. [PMID: 30165567 DOI: 10.1093/intqhc/mzy182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/22/2018] [Accepted: 08/03/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized. OBJECTIVE This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium. DESIGN Retrospective cohort analysis. SETTING AND PARTICIPANTS We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied. MAIN OUTCOME MEASURES The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed. RESULTS In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care. CONCLUSIONS Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, LLC 722 Elmbrook Drive Simpsonville, SC, USA.,Division of Gastroenterology, Department of Medicine, University of South Carolina, Columbia, SC, USA
| | - Scott Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Vlaanderen FP, Tanke MA, Bloem BR, Faber MJ, Eijkenaar F, Schut FT, Jeurissen PPT. Design and effects of outcome-based payment models in healthcare: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:217-232. [PMID: 29974285 PMCID: PMC6438941 DOI: 10.1007/s10198-018-0989-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/22/2018] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
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Affiliation(s)
- F P Vlaanderen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands.
| | - M A Tanke
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - B R Bloem
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - M J Faber
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | - F Eijkenaar
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - F T Schut
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P T Jeurissen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
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Hughes BD, Moore SA, Mehta HB, Shan Y, Senagore AJ. Diagnosis-Related Group in Colon Surgery: Identifying Areas of Improvement to Drive High-Value Care. Am Surg 2019. [DOI: 10.1177/000313481908500328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diagnosis-related group (DRG) migration is defined as the reassignment of colectomy patients from DRG 331 to 330 based exclusively on postoperative complications. Strategic and comparative application of this metric has the potential to demonstrate baseline and excessive rates of complications related directly to patient care differences across institutions. The aim of this study was to report the variability of DRG migration across United States hospitals and its impact on overall cost and length of stay (LOS). This study investigated the variability of DRG migration rates across United States hospitals polling 5 per cent of the national Medicare data. The study end-points were total cost, LOS, and DRG migration rate. Hospitals were classified into tertiles for low (0.1–16.6%), moderate (16.7–23.0%), and high (23.1–83.3%) DRG migration rates. The study included 5120 patients from 615 hospitals. DRG migration rates for hospitals ranged from 0.1 per cent to 83.3 per cent, with 157 in the low, 183 in the moderate, and 364 in the high tertile. DRG migration resulted in a progressively increased LOS and hospital costs from the lowest to highest tertile. Several diagnoses were identified which are suggestive of failure to integrate evidence-based processes of care across the tertiles. The data confirm a wide variation in DRG migration rates from DRG 331 to 330 based only on postoperative complications. These ranges allow for the potential definition of both best practice, and opportunities for quality improvement with respect to postoperative complications, identification of hospital outliers, and the economics of care as part of a value-based care program.
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Affiliation(s)
- Byron D. Hughes
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Samantha A. Moore
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | | | - Yong Shan
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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Hughes BD, Moore SA, Mehta HB, Shan Y, Senagore AJ. Diagnosis-Related Group in Colon Surgery: Identifying Areas of Improvement to Drive High-Value Care. Am Surg 2019; 85:256-260. [PMID: 30947770 PMCID: PMC6599513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Diagnosis-related group (DRG) migration is defined as the reassignment of colectomy patients from DRG 331 to 330 based exclusively on postoperative complications. Strategic and comparative application of this metric has the potential to demonstrate baseline and excessive rates of complications related directly to patient care differences across institutions. The aim of this study was to report the variability of DRG migration across United States hospitals and its impact on overall cost and length of stay (LOS). This study investigated the variability of DRG migration rates across United States hospitals polling 5 per cent of the national Medicare data. The study endpoints were total cost, LOS, and DRG migration rate. Hospitals were classified into tertiles for low (0.1-16.6%), moderate (16.7-23.0%), and high (23.1-83.3%) DRG migration rates. The study included 5120 patients from 615 hospitals. DRG migration rates for hospitals ranged from 0.1 per cent to 83.3 per cent, with 157 in the low, 183 in the moderate, and 364 in the high tertile. DRG migration resulted in a progressively increased LOS and hospital costs from the lowest to highest tertile. Several diagnoses were identified which are suggestive of failure to integrate evidence-based processes of care across the tertiles. The data confirm a wide variation in DRG migration rates from DRG 331 to 330 based only on postoperative complications. These ranges allow for the potential definition of both best practice, and opportunities for quality improvement with respect to postoperative complications, identification of hospital outliers, and the economics of care as part of a value-based care program.
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Abstract
Abstract
Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.
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Lam MB, Figueroa JF, Feyman Y, Reimold KE, Orav EJ, Jha AK. Association between patient outcomes and accreditation in US hospitals: observational study. BMJ 2018; 363:k4011. [PMID: 30337294 PMCID: PMC6193202 DOI: 10.1136/bmj.k4011] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations. DESIGN Observational study. SETTING 4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017. PARTICIPANTS 4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS). MAIN OUTCOME MEASURES Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission. RESULTS Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06). CONCLUSIONS US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.
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Affiliation(s)
- Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - Jose F Figueroa
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Yevgeniy Feyman
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - Kimberly E Reimold
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
| | - E John Orav
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Paine LA, Holzmueller CG, Elliott R, Kasda E, Pronovost PJ, Weaver SJ, Sutcliffe KM, Mathews SC. Latent risk assessment tool for health care leaders. J Healthc Risk Manag 2018; 38:36-46. [PMID: 29631323 DOI: 10.1002/jhrm.21316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/19/2017] [Accepted: 01/03/2018] [Indexed: 06/08/2023]
Abstract
Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks.
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Affiliation(s)
- Lori A Paine
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert Elliott
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | | | - Peter J Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins University, Baltimore, MD
| | - Sallie J Weaver
- Health Systems and Interventions Research Branch (HSIRB) of the Healthcare Delivery Research Program at the National Cancer Institute; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Kathleen M Sutcliffe
- Johns Hopkins University Carey Business School (Baltimore, MD); Johns Hopkins University School of Medicine (Baltimore, MD); Johns Hopkins University School of Nursing (Baltimore, MD); Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD
| | - Simon C Mathews
- Division of Gastroenterology, Johns Hopkins University School of Medicine (Baltimore, MD); Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD
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Affiliation(s)
- Ashish K Jha
- Harvard Global Health Institute, Harvard University, Cambridge, Massachusetts
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Norton EC, Li J, Das A, Chen LM. Moneyball in Medicare. JOURNAL OF HEALTH ECONOMICS 2018; 61:259-273. [PMID: 28823796 PMCID: PMC5794630 DOI: 10.1016/j.jhealeco.2017.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 04/24/2017] [Accepted: 07/07/2017] [Indexed: 05/19/2023]
Abstract
US policymakers place high priority on tying Medicare payments to the value of care delivered. A critical part of this effort is the Hospital Value-based Purchasing Program (HVBP), which rewards or penalizes hospitals based on their quality and episode-based costs of care and incentivizes integration between hospitals and post-acute care providers. Within HVBP, each patient affects hospital performance on a variety of quality and spending measures, and performance translates directly to changes in program points and ultimately dollars. In short, hospital revenue from a patient consists not only of the DRG payment, but also of that patient's marginal future reimbursement. We estimate the magnitude of the marginal future reimbursement for individual patients across each type of quality and performance measure. We describe how those incentives differ across hospitals, including integrated and safety-net hospitals. We find evidence that hospitals improved their performance over time in the areas where they have the highest marginal incentives to improve care, and that integrated hospitals responded more than non-integrated hospitals.
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Affiliation(s)
| | - Jun Li
- University of Michigan, United States
| | - Anup Das
- University of Michigan, United States
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Impact of Provider Participation in ACO Programs on Preventive Care Services, Patient Experiences, and Health Care Expenditures in US Adults Aged 18–64. Med Care 2018; 56:711-718. [DOI: 10.1097/mlr.0000000000000935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Ryan AM. Well-Balanced or too Matchy-Matchy? The Controversy over Matching in Difference-in-Differences. Health Serv Res 2018; 53:4106-4110. [PMID: 30047128 DOI: 10.1111/1475-6773.13015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
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Pross C, Geissler A, Busse R. Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability. Milbank Q 2018; 95:136-183. [PMID: 28266076 DOI: 10.1111/1468-0009.12248] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | - Reinhard Busse
- Berlin University of Technology.,European Observatory on Health Systems and Policies
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