Effects of the Premier Hospital Quality Incentive Demonstration on Medicare patient mortality and cost.
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ABSTRACT: Objective
To evaluate the effects of the Premier Inc. and Centers for Medicare and Medicaid Services Hospital Quality Incentive Demonstration (PHQID), a public quality reporting and pay-for-performance (P4P) program, on Medicare patient mortality, cost, and outlier classification.Data sources
The 2000-2006 Medicare inpatient claims, Medicare denominator files, and Medicare Provider of Service files.Study design
Panel data econometric methods are applied to a retrospective cohort of 11,232,452 admissions from 6,713,928 patients with principal diagnoses of acute myocardial infarction (AMI), heart failure, pneumonia, or a coronary-artery bypass grafting (CABG) procedure from 3,570 acute care hospitals between 2000 and 2006. Three estimators are used to evaluate the effects of the PHQID on risk-adjusted (RA) mortality, cost, and outlier classification in the presence of unobserved selection, resulting from the PHQID being voluntary: fixed effects (FE), FE estimated in the subset of hospitals eligible for the PHQID, and difference-in-difference-in-differences.Data extraction methods
Data were obtained from CMS. Principal Findings. This analysis found no evidence that the PHQID had a significant effect on RA 30-day mortality or RA 60-day cost for AMI, heart failure, pneumonia, or CABG and weak evidence that the PHQID increased RA outlier classification for heart failure and pneumonia.Conclusions
By not reducing mortality or cost growth, this study suggests that the PHQID has made little impact on the value of inpatient care purchased by Medicare.
SUBMITTER: Ryan AM
PROVIDER: S-EPMC2699910 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:The Medicare and Premier Inc. Hospital Quality Incentive Demonstration (HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance (Phase 1) to another rewarding high performance, moderate performance, and improvement (Phase 2). We tested whether this design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage.To estimate incentive payments in both phases, we used data from the Premier Inc. website and from Medicare Provider Analysis and Review files. We used data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services Impact File to identify hospital characteristics.Hospitals were divided into quartiles based on their Disproportionate Share Index (DSH), from lowest disadvantage (Quartile 1) to highest disadvantage (Quartile 4). In both phases of the HQID, we tested for differences across the DSH quartiles for three outcomes: (1) receipt of any incentive payments; (2) total incentive payments; and (3) incentive payments per discharge. For each of the study outcomes, we performed a hospital-level difference-in-differences analysis to test whether the gap between Quartile 1 and the other quartiles decreased from Phase 1 to Phase 2.In Phase 1, there were significant gaps across the DSH quartiles for the receipt of any payment and for payment per discharge. In Phase 2, the gap was not significant for the receipt of any payment, but it remained significant for payment per discharge. For the receipt of any incentive payment, difference-in-difference estimates showed significant reductions in the gap between Quartile 1 and the other quartiles (Quartile 2, 17.5 percentage points [p < .05]; Quartile 3, 18.1 percentage points [p < .01]; Quartile 4, 28.3 percentage points [p < .01]). For payments per discharge, the gap was also significantly reduced between Quartile 1 and the other quartiles (Quartile 2, $14.92 per discharge [p < .10]; Quartile 3, $17.34 per discharge [p < .05]; Quartile 4, $21.31 per discharge [p < .01]). There were no significant reductions in the gap for total payments.The design change in the HQID reduced the disparity in the receipt of any incentive payment and for incentive payments per discharge between hospitals caring for the most and least socioeconomically disadvantaged patient populations.
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Project description:BackgroundAlthough pay for performance (P4P) has become common, many worry that P4P will lead providers to avoid offering surgical procedures to the sickest patients out of concern that poor outcomes will lead to financial penalties.Methods and resultsWe used Medicare data to compare change in rates of coronary artery bypass graft surgery between 2002 to 2003 and 2008 to 2009 among patients with acute myocardial infarction (AMI) admitted to 126 hospitals participating in Medicare's Premier Hospital Quality Incentive Demonstration P4P program with patients in 848 control hospitals participating in public reporting through the Health Quality Alliance. We examined rates for all patients with AMI and those in the top decile of predicted mortality based on demographics, medical comorbidities, and AMI characteristics. We identified 91 393 patients admitted for AMI in Premier hospitals and 502 536 Medicare patients admitted for AMI in control hospitals. Coronary artery bypass graft surgery rates for patients with AMI in Premier decreased from 13.6% in 2002 to 2003 to 10.4% in 2008 to 2009; there was a comparable decrease in non-Premier hospitals (13.6%-10.6%; P value for comparison of changes between Premier and non-Premier, 0.67). Coronary artery bypass graft surgery rates for high-risk patients in Premier decreased from 8.4% in FY 2002 to 203 to 8.2% in 2008 to 2009. Patterns were similar in non-Premier hospitals (8.4%-8.3%; P value for comparison of changes between Premier and non-Premier, 0.82).ConclusionsOur results show no evidence of a deleterious effect of P4P on access to coronary artery bypass graft surgery for high-risk patients with AMI. These results should be reassuring to those concerned about the potential negative effect of P4P on high-risk patients.
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Project description:ObjectiveTo characterize the development and performance of a cataract surgery episode-based cost measure for the Medicare Quality Payment Program.DesignClaims-based analysis.ParticipantsMedicare clinicians with cataract surgery claims between June 1, 2016, and May 31, 2017.MethodsWe limited the analysis to claims with procedure code 66984 (routine cataract surgery), excluding cases with relevant ocular comorbidities. We divided episodes into subgroups by surgery location (Ambulatory Surgery Center [ASC] or Hospital Outpatient Department [HOPD]) and laterality (bilateral when surgeries were within 30 days apart). For the episode-based cost measure, we calculated costs occurring between 60 days before surgery and 90 days after surgery, limited to services identified by an expert committee as related to cataract surgery and under the influence of the cataract surgeon. We attributed costs to the clinician submitting the cataract surgery claim, categorized costs into clinical themes, and calculated episode cost distribution, reliability in detecting clinician-dependent cost variation, and costs with versus without complications. We compared episode-based cost scores with hypothetical "nonselective" cost scores (total Medicare beneficiary costs between 60 days before surgery and 90 days after surgery).Main outcome measuresEpisode costs with and without complications, clinician-dependent variation (proportion of total cost variance), and proportion of costs from cataract surgery-related clinical themes.ResultsWe identified 583 356 cataract surgery episodes attributed to 10 790 clinicians and 8189 with ≥ 10 episodes during the measurement period. Most surgeries were performed in an ASC (71%) and unilateral (66%). The mean episode cost was $2876. The HOPD surgeries had higher costs; geography and episodes per clinician did not substantially affect costs. The proportion of cost variation from clinician-dependent factors was higher in episode-based compared with nonselective cost measures (94% vs. 39%), and cataract surgery-related clinical themes represented a higher proportion of total costs for episode-based measures. Episodes with complications had higher costs than episodes without complications ($3738 vs. $2276).ConclusionsThe cataract surgery episode-based cost measure performs better than a comparable nonselective measure based on cost distribution, clinician-dependent variance, association with cataract surgery-related clinical themes, and quality alignment (higher costs in episodes with complications). Cost measure maintenance and refinement will be important to maintain clinical validity and reliability.Financial disclosuresProprietary or commercial disclosure may be found after the references.
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Project description:BackgroundThe Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods.ObjectiveThis study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program.Research design2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs.SubjectsA total of 3608 Medicare-certified hospitals in 50 US states.MeasuresHospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care.ResultsLower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [-3.3%; 95% confidence interval (CI), -4.7 to -2.0], no high-school diploma (-0.8%; 95% CI, -1.5 to -0.1), unemployment (-1.2%; 95% CI, -1.9 to -0.4), black race (-1.2%; 95% CI, -1.7 to -0.8), and high travel times to work (-2.5%; 95% CI, -3.3 to -1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups.ConclusionsHospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.
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Project description: Not available
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Project description:BackgroundRacial disparities in general surgical outcomes are known to exist but not well understood.ObjectivesTo determine if black-white disparities in general surgery mortality for Medicare patients are attributable to poorer health status among blacks on admission or differences in the quality of care provided by the admitting hospitals.Research designMatched cohort study using Tapered Multivariate Matching.SubjectsAll black elderly Medicare general surgical patients (N=18,861) and white-matched controls within the same 6 states or within the same 838 hospitals.MeasuresThirty-day mortality (primary); others include in-hospital mortality, failure-to-rescue, complications, length of stay, and readmissions.ResultsMatching on age, sex, year, state, and the exact same procedure, blacks had higher 30-day mortality (4.0% vs. 3.5%, P<0.01), in-hospital mortality (3.9% vs. 2.9%, P<0.0001), in-hospital complications (64.3% vs. 56.8% P<0.0001), and failure-to-rescue rates (6.1% vs. 5.1%, P<0.001), longer length of stay (7.2 vs. 5.8 d, P<0.0001), and more 30-day readmissions (15.0% vs. 12.5%, P<0.0001). Adding preoperative risk factors to the above match, there was no significant difference in mortality or failure-to-rescue, and all other outcome differences were small. Blacks matched to whites in the same hospital displayed no significant differences in mortality, failure-to-rescue, or readmissions.ConclusionsBlack and white Medicare patients undergoing the same procedures with closely matched risk factors displayed similar mortality, suggesting that racial disparities in general surgical mortality are not because of differences in hospital quality. To reduce the observed disparities in surgical outcomes, the poorer health of blacks on presentation for surgery must be addressed.
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