Medicare's Hospital P4P Program Provides Greater Incentives to Already High-Performers
A study of Medicare's flagship hospital pay-for-performance (P4P) program—the Premier Hospital Quality Incentive Demonstration, begun in 2003—examined the effects of a new incentive design, introduced in 2006, that was aimed at encouraging quality improvement, particularly among lower-performing hospitals. The study found that the new incentive design failed to achieve this goal. Hospitals in the incentive program improved no more than others and, rather than promoting improvement in lower-performing hospitals, the program created the strongest incentives for hospitals that had already achieved quality performance ratings just above the median among all participating hospitals. The study's findings cast some doubt on the extent to which hospitals respond to the specific structure of economic incentives in pay-for-performance programs. A. M. Ryan, J. Blustein, and L. P. Casalino, "Medicare's Flagship Test of Pay-for-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals," Health Affairs, April 2012 31(4):797–805.
Multidisciplinary Teams Lead to Higher Breast Cancer Survival Rates
The use of multidisciplinary teams to treat patients with symptomatic invasive breast cancer in hospitals in Scotland was associated with improved survival and reduced variation in survival rates. The study found that before the before the introduction of multidisciplinary teams, breast cancer mortality was 11 percent higher in the intervention group than in the non-intervention group. After multidisciplinary care was introduced, breast cancer mortality was 18 percent lower in the intervention group than in the non-intervention group. E. M. Kesson, G. M. Allardice, W. D. George et al., "Effects of Multidisciplinary Team Working on Breast Cancer Survival: Retrospective, Comparative, Interventional Cohort Study of 13,722 Women," BMJ, published April 26, 2012.
Patient Characteristics Influence High Performance at Physician-Owned Cardiac Specialty Hospitals
A study designed to determine whether the higher performance of physician-owned cardiac specialty hospitals was tied to the physicians practicing there or other factors examined mortality rates for percutaneous coronary interventions by physician to see if the results were similar in both specialty and general hospitals, as would be expected if physicians were responsible for the outcomes. The study found this was not the case: physician-specific mortality rates were higher when the doctors who owned cardiac specialty hospitals treated patients in general hospitals, suggesting other factors may be at play. Testing whether patient selection might explain their worse performance in general hospitals, they found certain patient characteristics were in fact associated with a lower likelihood of being admitted to a cardiac hospital for cardiac care. These included being African American or Hispanic and having Medicaid or no health insurance. The results suggest that lower mortality rates at specialty hospitals are traceable to healthier patients and to doctors' performing more procedures rather than physician performance. L. O'Neill and A. J. Hartz, "Lower Mortality Rates at Cardiac Specialty Hospitals Traceable to Healthier Patients and to Doctors' Performing More Procedures," Health Affairs, April 2012 31(4):806–15.
Patient Activation Tied to Better Outcomes for Patients
Researchers examining the degree to which patient activation is related to a broad range of patient health and utilization outcomes in a large, insured population found that for every 10 additional points in patient activation scores, the predicted probability of having an emergency department visit, being obese, or smoking was one percentage point lower. The likelihood of having a breast cancer screening or clinical indicators in the normal range (A1c, HDL, and triglycerides) was one percentage point higher. J. Greene and J. H. Hibbard, "Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes," Journal of General Internal Medicine, May 2012 27(5):520–26.
Study of Medicare P4P for Hospitals Finds No Impact on Mortality Rates
Researchers assessing the long-term impact of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes found no evidence that the nation's largest hospital-based pay-for-performance program led to a decrease in 30-day mortality rates. Outcomes for patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) at hospitals participating in the Premier HQID were similar at baseline to those of patients at non-Premier hospitals and rates of decline in mortality per quarter were similar at the two types of hospitals. The researchers also found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and conditions not linked to incentives (congestive heart failure and pneumonia). A. K. Jha, K. E. Joynt, E. J. Orav et al., "The Long-Term Effect of Premier Pay for Performance on Patient Outcomes," New England Journal of Medicine, April 2012 366(17):1606–15.
Revision to Medicare's Readmission Policy Proposed
A commentary in the New England Journal of Medicine suggests the Centers for Medicare and Medicaid Services should pursue a different approach to reducing avoidable hospital readmissions. Rather than penalizing hospitals for readmissions related to hospital-acquired infections and premature discharge among other problems, the authors recommend following the model of Geisinger Health System, which offers a warranty that covers all services related to the condition for a designated period of time. The authors contend this approach would provide hospitals an incentive to improve care and reduce costs, as opposed to the current model, which presents only nominal downside risk. Using an approach similar to Geisinger's would reduce reimbursement for readmissions, thus generating immediate savings, but would still provide incentive for hospitals to address some of the causes of avoidable readmissions, such as inadequate communication among hospital personnel and poor planning for care transitions, as the savings from such programs would accrue to the hospitals. R. A. Berenson, R. A. Paulus, and N. S. Kalman, "Medicare's Readmissions-Reduction Program — A Positive Alternative," New England Journal of Medicine, April 2012 366(15):1364–66.
Team-Based Care Recommended to Reduce the Impact of Primary Care Physician Shortages
A commentary published in the New England Journal of Medicine recommends that primary care physicians adopt a team-based approach to care—with registered nurses, medical assistants, health educators, and others taking responsibility for prescription refills and chronic disease care by following evidence-based standards that have been developed by the physicians for their panel of patients. According to the commentary, handling prescription refills and chronic disease care accounts for 17 percent and 37 percent, respectively, of primary care physicians' time. The authors contend that using a team-based model also would help overcome the nation's shortage of primary care physicians, which is expected to worsen as the population ages and demand for primary care services increases. A. Ghorob and T. Bodenheimer, "Sharing the Care to Improve Access to Primary Care," New England Journal of Medicine, May 2012 366(21): 1955–57.
Using the Nuclear Power Industry's Methods to Increase Patient Safety
To address the health care industry's sluggish progress in improving patient safety, an article published in the American Journal of Medical Quality proposes that the industry adopt the prospective peer-to-peer (P2P) assessment model used by the nuclear power industry to identify and mitigate hazards. The P2P model relies on an in-depth, objective evaluation by an independent and nonregulatory team of peers with extensive experience in best practices to identify an institution's strengths and weaknesses in identifying and mitigating safety hazards. D. W. Hudson, C. G. Holzmueller, P. J. Pronovost et al., "Toward Improving Patient Safety Through Voluntary Peer-to-Peer Assessment," American Journal of Medical Quality, May/June 2012 27(3):201–9.
In Large P4P Program, Providers in Poorer Areas Fare Worse Than Those in Richer Areas
A study of the Integrated Healthcare Association's (IHA's) Pay-for-Performance Program, the largest non-governmental, multi-payer pay-for-performance program for physician organizations in the U.S., found that the performance scores of independent practice associations and medical groups varied by the socioeconomic status (SES) area in which their practice sites were located. P4P programs that do not account for this are likely to pay higher bonuses to physician organizations in higher SES areas, thus increasing the resource gap between these physician organizations and physician organizations in lower SES areas, which may in turn exacerbate disparities in the care they provide. A. T. Chien, K. Wroblewski, C. Damberg et al., "Do Physician Organizations Located in Lower Socioeconomic Status Areas Score Lower on Pay-for-Performance Measures?" Journal of General Internal Medicine, May 2012 27(5):548–54.
Improved Diabetes Care Linked to Teamwork at Veterans' Hospitals
Researchers seeking to identify best practices in outpatient diabetes care and the factors associated with their development used the Veteran Health Administration's diabetes registry to identify high-, mid-, and low-performing facilities and outpatient clinics. After conducting telephone interviews and site visits, the researchers found that low performers attributed their results to a lack of teamwork between physicians and nurses and inadequate time to prepare for patient visits. Better-performing sites attributed their performance to supportive clinical teams sharing work and innovative practices to address local needs, among other factors. S. Kirsh, M. Hein, L. Pogach et al., "Improving Outpatient Diabetes Care," American Journal of Medical Quality, May/June 2012 27(3):233–40.
Mortality Rates Following AMI Better in Hospitals with Clinician-Directed QI Programs
A study of mortality rates following acute myocardial infarction (AMI) found these rates vary greatly among U.S. hospitals even after accounting for patient factors. The survey of 537 U.S. hospitals identified several strategies associated with lower mortality after AMI: a culture that encouraged physicians to solve problems creatively, physicians and nurses acting as quality-of-care champions, hospital and emergency department clinicians meeting at least monthly to review care, cardiologists always being present in the hospital, and not cross-training nurses to work in both intensive care and cardiac catheterization settings. However, less than 10 percent of hospitals reported using at least four of the five strategies. E. H. Bradley, L. A. Curry, E. S. Spatz et al., "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," Annals of Internal Medicine, May 2012 156(9):618–26.