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#Grand Rounds

Do Pay for Performance Incentives Enhance Hospital Performance?

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BACKGROUND AND PURPOSE:

  • Premier Hospital Quality Incentive Demonstration (HQID), was a voluntary Centers for Medicare and Medicaid Services (CMS) program that operated between 2003 and 2009
  • The national Hospital Value-Based Purchasing (HVBP) program was implemented in 2011, based on HQID
  • Initial evaluations of the HDIQ and HVBP program showed limited impact on improvement in patient outcomes or cost reduction
  • It is possible that it may take time to see improvement
  • Bonfrer et al. (BMJ, 2018) compared early adopter volunteer hospitals to later adopters over a decade (2003-2013)

METHODS:

  • Observational study
  • Participants: Patients aged 65 years and older using 100% Medicare claims
  • 2,702 American acute care hospitals in 2013 were participating in HVBP
    • 233 hospitals were identified as early adopters
  • The researchers took in account the following potential confounders
    • Size, region, ownership, teaching status, location, presence of an intensive care unit, and safety net status
  • Data on clinical process scores (range from 0 to 100) were obtained for each hospital
    • Clinical process scores assess whether “what is known to be ‘good’ medical care has been applied (according to CMS)
    • 3 HVBP conditions that were targeted: Acute myocardial infarction, congestive heart failure, and pneumonia
  • Primary outcomes:
    • Clinical process scores
    • 30-day mortality

RESULTS:

  • 263,088 patients were admitted to early adopter hospitals and 1,108,276 were admitted to late adopter hospitals
  • Early adopters started from a slightly higher baseline of clinical process scores (92) than late adopters (90)
  • Both reached a ceiling (98) 10 years later
  • Early and late adopters did not have significantly different mortality trends for conditions targeted by the program or for conditions not targeted by the program

CONCLUSION:

  • Hospitals that underwent performance programs for more than a decade did not have a significantly better process scores or lower mortality, compared to other hospitals
  • The authors state that “additional time is not likely to turn these programs into a success”
  • Possible hypotheses include
    • Incentives are too small and only cover a small set of conditions
    • Revenues come from many payors, not just CMS

Learn More – Primary Sources:

Impact of Financial Incentives on Early and Late Adopters among US Hospitals: observational study

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