From the Journals

Analysis: Hospital pay for performance not significantly improving Medicare outcomes

Dr. Michael E. Nelson, FCCP

Michael E. Nelson, MD, FCCP, comments: The most objective assessment of a process often comes from an independent review by an uninvolved party. This study using "Big Data" calls into question the hypothesis that the carrot may work more effectively than the stick, at least in the realm of hospital care. Sometimes the only way to know if something will work is to try it, but then make appropriate adjustments should the plan fail ¬ a colloquial way to describe scientific method. It will be interesting to see if CMS responds to this information with an adjustment in policy.



Hospital pay-for-performance programs are not leading to significant improvements in clinical process scores or 30-day mortality rates for Medicare beneficiaries, according to an analysis of Medicare claims data.

“No evidence that hospitals [that were] operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found,” Igna Bonfrer, PhD, of Erasmus University, Rotterdam, the Netherlands, and colleagues wrote in a study published Jan. 4, 2018, in BMJ.

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“These findings suggest that, even among hospitals that volunteered to participate in pay for performance programs, having additional time is not likely to turn pay for performance programs into a success in the future,” the investigators noted.

Researchers looked at Medicare claims data from nearly 1.4 million patients aged 65 years and older across 1,189 hospitals. That total included 214 hospitals that were early adopters of pay for performance (PFP) programs, including the Hospital Quality Incentive Demonstration (HQID) and the current Hospital Value-Based Purchasing (HVBP) program, and 975 hospitals that adopted the programs at a later date. The study authors examined clinical process scores and 30-day mortality rates from 2003 to 2013.

Hospitals that were early adopters of a PFP program typically started from a higher baseline process measure score (91.5), compared with late adopters (89.9).

However, improvements among the early adopters “were smaller during the HQID period, although early adopters continued to perform at a slightly higher level than the late adopters during the pre-HVBP period,” the researchers explained. “Over the HVBP period, early and late adopters no longer differed in their clinical process scores.”

Indeed, a ceiling was ultimately reached, with early and late adopters approaching the same level (98.5 vs. 98.2).

For the 30-day mortality rates, both groups “started from a similar baseline (14.9% and 14.8% for the early and late adopters in the fourth quarter of 2003) and ended at the same rate of 9.9% for both groups in the fourth quarter of 2013,” Dr. Bonfrer and colleagues wrote.

The researchers suggested that the programs did not yield better results because of small financial incentives, coupled with program complexities that made it “difficult for hospitals to meaningfully engage in the program.” They also suggested that having to wait until year end to receive any financial incentives could have limited the impact.

“We found that hospitals that have been under financial incentives for more than a decade have not been able to reduce patient mortality more than late adopters, which had only been under financial incentives for less than 3 years,” the researchers concluded. “Given its cost, policymakers in the [United States] should consider one of two things: revise the current program or potentially end it.”

The changes suggested include increasing financial incentives and focusing on process measures that matter most to patients (mortality, patient experience, and functional status), rather than the current measure set that is larger and more difficult to track.

The researchers did not report any financial conflicts of interest.

SOURCE: Dr. Igna Bonfrer et al. BMJ 2018;360:j5622.

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