Grand Rounds

Do Pay for Performance Incentives Enhance Hospital Performance?

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)

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

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

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

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