Pay­ers should only re­ward pro­grams that im­prove out­comes

Pay­ers should re­ward only pro­grams that im­prove out­comes

Modern Healthcare - - NEWS - MER­RILL GOOZNER Ed­i­tor

Un­der Medi­care’s new­est pay-for-per­for­mance pro­gram, hos­pi­tals re­ceive re­wards or penal­ties for meet­ing process per­for­mance and pa­tient-sat­is­fac­tion goals. The pro­gram, bet­ter-known as value-based pur­chas­ing, or VBP, as­sumes cor­rectly that pa­tients will fare bet­ter if hos­pi­tals im­prove the pro­cesses by which they de­liver care.

A lot of re­search went into de­vel­op­ing the VBP plan. Numer­ous stud­ies showed a strong re­la­tion­ship be­tween us­ing best prac­tices and bet­ter out­comes. What was much less clear in the med­i­cal lit­er­a­ture was whether im­prov­ing a pa­tient’s per­cep­tions about the qual­ity of care would have a sim­i­lar im­pact. Re­cent re­search is di­vided on the ques­tion, an is­sue raised at last month’s meet­ing of the Medi­care Pay­ment Ad­vi­sory Com­mis­sion (See story, p. 32).

An anal­y­sis by Mod­ern Health­care (See story, p. 6) would seem to bear out the con­tention that some­thing is amiss with VBP, at least as it is cur­rently struc­tured. Our re­porters com­pared its re­wards and penal­ties to the other new Medi­care per­for­mance pro­gram ini­ti­ated un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act: penal­ties for read­mis­sions.

Un­der the VBP pro­gram, hos­pi­tals were ei­ther re­warded or pe­nal­ized up to 1% of their to­tal Medi­care re­im­burse­ment based on a suite of 13 process mea­sures, in­clud­ing the govern­men­tap­proved hospi­tal sur­vey of pa­tient sat­is­fac­tion. The re­ward sys­tem was weighted 70% for process mea­sures and 30% for pa­tient sat­is­fac­tion.

The sec­ond pro­gram, whose first-year re­sults were an­nounced in Novem­ber, pe­nal­ized hos­pi­tals up to 1% of re­im­burse­ment for ex­ces­sive rates of read­mis­sion, a hard out­comes mea­sure.

Our com­par­i­son found there was only a weak cor­re­la­tion be­tween the VBP re­wards/penal­ties and read­mis­sion penal­ties. In fact, more than 41% of the hos­pi­tals that scored best on read­mis­sions—they re­ceived no penalty—were pe­nal­ized for their per­for­mance on pro­cesses and pa­tient satis- fac­tion. On the other side of the spec­trum, more than 42% of the hos­pi­tals that re­ceived a max­i­mum 1% penalty on read­mis­sions were re­warded for their process and pa­tient-sat­is­fac­tion per­for­mance.

There are numer­ous pos­si­ble ex­pla­na­tions for the di­ver­gence be­tween process per­for­mance and out­comes at nearly half of all hos­pi­tals. Mor­tal­ity and over­all health, which have yet to be in­cluded in a Medi­care re­wards pro­gram, may be more im­por­tant out­come mea­sures than read­mis­sions. The process mea­sures used by Medi­care, gleaned from re­im­burse­ment records, may not be the most im­por­tant in driv­ing out­comes. Tim­ing may also be a fac­tor—how much can in­hos­pi­tal pro­cesses really de­ter­mine read­mis­sion rates; it may be that over­all sys­tem per­for­mance needs to be re­warded or pe­nal­ized, not just the hos­pi­tals.

The weak link be­tween pa­tient sat­is­fac­tion and fi­nal out­comes also needs to be taken into ac­count. Are ques­tions about the clean­li­ness or noise lev­els in hos­pi­tals really rel­e­vant? Does a zero on “How of­ten did nurses ex­plain things in a way you could un­der­stand?” trans­late into worse out­comes? Writ­ing late last month in the New Eng­land Jour­nal of Medicine, de­fend­ers of pa­tient-sat­is­fac­tion sur­veys—some of whom are fi­nan­cially in­volved in de­vel­op­ing their own sur­vey meth­ods—vig­or­ously de­fended pa­tient ex­pe­ri­ence sur­veys “when de­signed and ad­min­is­tered ap­pro­pri­ately.” Go­ing far­ther, some an­a­lysts have crit­i­cized Medi­care’s re­wards and penal­ties for be­ing too small to in­flu­ence provider be­hav­ior. The im­pli­ca­tion is that the government should move quickly to raise the stakes.

That would be a mis­take. Medi­care and other pay­ers us­ing pay-for-per­for­mance and other in­cen­tive pro­grams must be sure they are re­ward­ing and pe­nal­iz­ing the right pro­cesses—ones that truly im­prove out­comes. And if hos­pi­tals and providers are go­ing to be asked to throw pa­tient sat­is­fac­tion into the mix, the ques­tions asked must not con­fuse feel­ing good with get­ting bet­ter.

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