Medicare program; hospital inpatient value-based purchasing program. Final rule.
This final rule implements a Hospital Inpatient Value-Based Purchasing program (Hospital VBP program or the program) under section 1886(o) of the Social Security Act (the Act), under which value-based incentive payments will be made in a fiscal year to hospitals that meet performance standards with respect to a performance period for the fiscal year involved. The program will apply to payments for discharges occurring on or after October 1, 2012, in accordance with section 1886(o) (as added by section 3001(a) of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act)). Scoring in the Hospital VBP program will be based on whether a hospital meets or exceeds the performance standards established with respect to the measures. By adopting this program, we will reward hospitals based on actual quality performance on measures, rather than simply reporting data for those measures.
Available from: Karen E Joynt
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ABSTRACT: We sought to determine whether the changes in incentive design in phase 2 of Medicare's flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals.
The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown.
We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates.
After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92-1.28] or joint replacement (OR = 0.81; 95% CI, 0.58-1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97-1.14) or joint replacement (OR = 1.12; 95% CI, 1.01-1.23). Analysis of the "worst" quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78-1.32) for CABG and (OR = 0.96; 95% CI, 0.22-4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88-1.34) for CABG and (OR = 0.92; 95% CI, 0.67-1.28) for joint replacement].
Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.
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ABSTRACT: Performance assessments based on in-hospital mortality for ICU patients can be affected by discharge practices such that differences in mortality may reflect variation in discharge patterns rather than quality of care. Time-specific mortality rates, such as 30-day mortality, are preferred but are harder to measure. The degree to which the difference between 30-day and in-hospital ICU mortality rates-or "discharge bias"-varies by hospital type is unknown. The aim of this study was to quantify variation in discharge bias across hospitals and determine the hospital characteristics associated with greater discharge bias.
Retrospective cohort study.
Nonfederal Pennsylvania hospital discharges in 2008.
Eligible patients were 18 years old or older and admitted to an ICU.
We used logistic regression with hospital-level random effects to calculate hospital-specific risk-adjusted 30-day and in-hospital mortality rates. We then calculated discharge bias, defined as the difference between 30-day and in-hospital mortality rates, and used multivariable linear regression to compare discharge bias across hospital types. A total of 43,830 patients and 134 hospitals were included in the analysis. Mean (SD) risk-adjusted hospital-specific in-hospital and 30-day ICU mortality rates were 9.6% (1.3) and 12.7% (1.5), respectively. Hospital-specific discharge biases ranged from -1.3% to 6.6%. Discharge bias was smaller in large hospitals compared with small hospitals, making large hospitals appear comparatively worse from a benchmarking standpoint when using in-hospital mortality instead of 30-day mortality.
Discharge practices bias in-hospital ICU mortality measures in a way that disadvantages large hospitals. Accounting for discharge bias will prevent these hospitals from being unfairly disadvantaged in public reporting and pay-for-performance.
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