Hospital Value-Based Purchasing Program Research Articles

The Impact of Hospitalists on Value-Based Purchasing Program Scores

As part of the provisions of the 2010 Affordable Care Act, the Centers for Medicare & Medicaid Services adjusts payments made to hospitals through its Hospital Value-Based Purchasing (HVBP) program. In light of the increasing aim to improve efficiency, healthcare organizations are exploring innovative strategies for care delivery, including the use of hospitalists. Supporters of the hospitalist model suggest use of these specialists offers several advantages over the traditional model of physician care in the inpatient setting, including improved coordination, reduced costs, and improved quality indicator scores. This study explores the effect of hospitalists on hospitals' scores in the four domains of the fiscal year 2016 HVBP program: clinical process of care, patient experience of care (PEOC), outcome, and efficiency. Data from the 2015 HVBP database, the 2015 Medicare Final Rule Standardizing File, and the 2015 American Hospital Association database were used for the analysis. The study used multivariate regression analysis in Stata 12. Results from this study suggest that hospitals employing a higher percentage of hospitalists see related improvement in their overall total performance score. In light of improvements within the PEOC, outcome, and efficiency scores, it would appear that hospitalists are primarily providing linking services, which helps provide better coordination of care that is otherwise lacking in more traditionally fragmented approaches to care.

Medicare Payment Penalties and Safety Net Hospital Profitability: Minimal Impact on These Vulnerable Hospitals.

To examine relationships between penalties assessed by Medicare's Hospital Readmission Reduction Program and Value-Based Purchasing Program and hospital financial condition. Centers for Medicare and Medicaid Services, American Hospital Association, and Area Health Resource File data for 4,824 hospital-year observations. Bivariate and multivariate analysis of pooled cross-sectional data. Safety net hospitals have significantly higher HRRP/VBP penalties, but, unlike nonsafety net hospitals, increases in their penalty rate did not significantly affect their total margins. Safety net hospitals appear to rely on nonpatient care revenues to offset higher penalties for the years studied. While reassuring, these funding streams are volatile and may not be able to compensate for cumulative losses over time.

Improving the quality of patient experience through student engagement.

The Centers for Medicare and Medicaid Services established the hospital value-based purchasing program, which began in fiscal year (FY) 2013 and applies to incentive payments to hospitals based on the quality of care provided to patients.[1][1] The quality of patient experience provided is captured

Impact of Financial Incentives on Early and Late Adopters among US Hospitals: observational study

ObjectiveTo examine how hospitals that volunteered to be under financial incentives for more than a decade as part of the Premier Hospital Quality Incentive Demonstration (early adopters) compared with similar...

Hospital Value-Based Purchasing Performance: Do Organizational and Market Characteristics Matter?

The hospital value-based purchasing (HVBP) program of the Centers for Medicare & Medicaid Services challenges hospitals to deliver high-quality care or face a reduction in Medicare payments. How do different organizational structures and market characteristics enable or inhibit successful transition to this new model of value-based care? To address that question, this study employs an institutional theory lens to test whether certain organizational structures and market characteristics mediate hospitals' ability to perform across HVBP domains.Data from the 2014 American Hospital Association Annual Survey Database, Area Health Resource File, the Medicare Hospital Compare Database, and the association between external environment and hospital performance are assessed through multiple regression analysis. Results indicate that hospitals that belong to a system are more likely than independent hospitals to score highly on the domains associated with the HVBP incentive arrangement. However, varying and sometimes counterintuitive market influences bring different dimensions to the HVBP program. A hospital's ability to score well in this new value arrangement may be heavily based on the organization's ability to learn from others, implement change, and apply the appropriate amount of control in various markets.

Dually Enrolled Beneficiaries Have Higher Episode Costs On The Medicare Spending Per Beneficiary Measure.

Cost measures are a growing part of Medicare's value-based payment programs. Medicare Spending per Beneficiary (MSPB) is the cost measure included in Medicare's Hospital Value-Based Purchasing (VBP) Program. Beneficiaries who are dually enrolled in Medicare and Medicaid are known to have higher spending on care, but it is unknown whether spending on the MSPB measure varies based on dual enrollment and whether this has implications for the performance of safety-net hospitals. We found that after adjustment for comorbidities, dually enrolled beneficiaries had 4.3percent higher spending, which was primarily driven by higher costs in the postacute setting associated with use of institutional postacute care. Hospitals in the highest quintile of the disproportionate share hospital index had poorer performance on the MSPB measure, and were more likely to be penalized under VBP. After adjustment for dual status, differences in MSPB performance between safety-net and non-safety-net hospitals were no longer significant. This suggests that differences in performance between the two types of hospitals were driven at least in part by differences in their patient populations. However, overall VBP payment impacts were largely unchanged after the MSPB measure was adjusted for dual-enrollment status.

Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores

BackgroundThe Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value-Based Purchasing Program. MethodsA multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight-adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. ResultsA total of 1,470 cases were flagged for PSI over a 2-year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of $111,773. ConclusionMultidisciplinary review processes are practical and effective in identifying false-positive patient safety events. The real-time process affects hospital performance and resultant Medicare reimbursement substantially.

HCAHPS survey to measure pain communication, not management.

Starting with patients discharged on January 1, hospitals and vendors administering the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will ask 3 questions concerning communication about pain during the hospital stay. The 3 questions replace the ones about pain management that have appeared in the survey for the past several years. Items 12, 13, and 14 on the 2018 version of the survey ask recently discharged adults to answer the following questions: These changes stem from a decision announced a year ago by the Centers for Medicare and Medicaid Services (CMS) to remove the survey’s pain management measures from the Hospital Value-Based Purchasing (VBP) Program. The 6-year-old CMS program links an acute care hospital’s performance on a set of quality measures to a portion of the agency’s Medicare reimbursements under the inpatient prospective payment system. A low-scoring hospital can have up to 2% of reimbursements withheld, while a top scorer can receive the equivalent of a 2% bonus. One fourth of a hospital’s total performance score comes from HCAHPS survey data. The survey’s pain management measures had been part of the program since its beginning. CMS indicated that some stakeholders have expressed concern that with inclusion of those measures on the survey, a hospital’s staff could feel pressured to prescribe more opioids so that the hospital would receive higher HCAHPS scores for pain management.

Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency.

The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.

Hospital Consumer Assessment of Healthcare Providers and Systems Scores Do Not Predict Outcomes After Total Hip Arthroplasty

BackgroundWith the establishment of the Hospital Value-Based Purchasing program, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score has been incorporated into the calculation of the total performance score, which determines redistribution of up to 2% of Medicare payments. This study aims to assess whether the HCAHPS score correlates with validated outcome measures after total hip arthroplasty. MethodsData from 63 patients who underwent a total hip arthroplasty and completed both an HCAHPS score and patient-reported outcome measures (PROMs) at our institution during the study period from January 1, 2015 to September 2016 were analyzed. The HCAHPS overall hospital rating scores were correlated with the preoperative to postoperative change in validated PROMs, namely EuroQol-EQ-5D Instrument and Hip Disability and Osteoarthritis Outcome Score. ResultsThere was no statistically significant correlation between the HCAHPS overall hospital rating score and PROMs. ConclusionThis study shows a lack of correlation between established validated PROMs used in orthopedic surgery, and the HCAHPS survey scores, an important determinant of compensation in the pay-for-performance reimbursement models.

76 - A Comparison of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Scores Between Lumbar Decompression and Lumbar Fusion Surgery Patients

BACKGROUND CONTEXT: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey has made patient experience a key driver of quality and reimbursement for hospital systems and spine surgeons nationwide. The HCAHPS survey is administered to a random sample of recently discharged adult patients across all medical specialties. The Centers for Medicare and Medicaid Services (CMS) use HCAHPS data to 1) calculate value-based incentive payments in the Hospital Value-Based Purchasing Program and 2) publicly report on the patient experiences of participating hospitals on the Hospital Compare website. In the setting of spine surgery, lumbar fusion surgery is associated with increased risk of major complications and higher utilization of resources when compared to lumbar decompression surgery. However, differences in patient experience scores between these two types of surgeries are not known.

Messy but Fair: The ACA's Hospital Value-Based Purchasing Program and the Notice-and-Comment Process

The Centers for Medicare and Medicaid Services (CMS) promulgated a new Medicare program called the Value-Based Purchasing Program (VBPP) as part of the 2010 Affordable Care Act (ACA). Like many other regulatory agencies, CMS used the Notice-and-Comment process to issue proposed rules, solicit public comments, and then publish final rules. Conventional literature suggests that CMS should disproportionately favor business interests during the Notice-and-Comment process, mainly due to the business interests' greater resources and capacity to draft well-reasoned comments. However, this article argues against this presumption and contends instead that CMS listens equally well to both business interest comments and private citizen comments during the formation of the VBPP. With regard to the VBPP and the ACA, CMS appears to be resisting disproportionate sway by business interests and is instead privileging the ACA's goal of improving healthcare quality.

Age Differences in Hospital Mortality for Acute Myocardial Infarction: Implications for Hospital Profiling.

Publicly reported hospital risk-standardized mortality rates (RSMRs) for acute myocardial infarction (AMI) are calculated for Medicare beneficiaries. Outcomes for older patients with AMI may not reflect general outcomes. To examine the relationship between hospital 30-day RSMRs for older patients (aged ≥65 years) and those for younger patients (aged 18 to 64 years) and all patients (aged ≥18 years) with AMI. Retrospective cohort study. 986 hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines. Adults hospitalized for AMI from 1 October 2010 to 30 September 2014. Hospital 30-day RSMRs were calculated for older, younger, and all patients using an electronic health record measure of AMI mortality endorsed by the National Quality Forum. Hospitals were ranked by their 30-day RSMRs for these 3 age groups, and agreement in rankings was plotted. The correlation in hospital AMI achievement scores for each age group was also calculated using the Hospital Value-Based Purchasing (HVBP) Program method computed with the electronic health record measure. 267763 and 276031 AMI hospitalizations among older and younger patients, respectively, were identified. Median hospital 30-day RSMRs were 9.4%, 3.0%, and 6.2% for older, younger, and all patients, respectively. Most top- and bottom-performing hospitals for older patients were neither top nor bottom performers for younger patients. In contrast, most top and bottom performers for older patients were also top and bottom performers for all patients. Similarly, HVBP achievement scores for older patients correlated weakly with those for younger patients (R= 0.30) and strongly with those for all patients (R= 0.92). Minority of U.S. hospitals. Hospital mortality rankings for older patients with AMI inconsistently reflect rankings for younger patients. Incorporation of younger patients into assessment of hospital outcomes would permit further examination of the presence and effect of age-related quality differences. American College of Cardiology.

Does value-based purchasing affect US hospital utilization pattern: A comparative study

ABSTRACTWe evaluated the effect US hospital performance as measured by the Medicare hospital value-based purchasing (HVBP) program has on the volume of hospitals inpatient and outpatient services. We analyzed data from the 2013 to 2014 American Hospital Association database, HVBP total performance scores database through Centers for Medicare and Medicaid Services (CMS) and the area health resources files database through CMS. This study utilized a multinomial logistic regression and transaction cost economic theory, adjusting for the Herfindahl–Hirschman Index, number of facility beds, beds per thousand, individuals 65+, teaching status, location, ownership, and system affiliation. The prominent study findings indicate a significant relationship between percent utilization of inpatient, outpatient and HVBP score. Furthermore, environmental factors such as the Herfindahl–Hirschman Index, and system participation were found to significantly impact hospitals ratio of inpatient to outpatient. Relative risk ratios show that hospitals with overall lower HVB are more likely to be in the top 25 percentile for outpatient services. With the decline in inpatient volume of services and the rise in outpatient utilization, inpatient metrics will continue to be relevant as key indicators of quality of care. Inpatient services will never become irrelevant to the overall financial profile of hospital performance.

Moneyball in Medicare

US policymakers place high priority on tying Medicare payments to the value of care delivered. A critical part of this effort is the Hospital Value-based Purchasing Program (HVBP), which rewards or penalizes hospitals based on their quality and episode-based costs of care and incentivizes integration between hospitals and post-acute care providers. Within HVBP, each patient affects hospital performance on a variety of quality and spending measures, and performance translates directly to changes in program points and ultimately dollars. In short, hospital revenue from a patient consists not only of the DRG payment, but also of that patient’s marginal future reimbursement. We estimate the magnitude of the marginal future reimbursement for individual patients across each type of quality and performance measure. We describe how those incentives differ across hospitals, including integrated and safety-net hospitals. We find evidence that hospitals improved their performance over time in the areas where they have the highest marginal incentives to improve care, and that integrated hospitals responded more than non-integrated hospitals.

Nurse communication's effect on CMS Star Ratings.

The Affordable Care Act of 2010 was the catalyst for a drastic shift in healthcare that included restructuring hospital reimbursements. Under the Hospital Value-Based Purchasing Program, the Centers for Medicare and Medicaid Services (CMS) began rewarding hospitals based on the quality of care, the

Elements of Program Design in Medicare's Value-based and Alternative Payment Models: a Narrative Review.

Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context. We found that current Medicare payment models vary significantly across each parameter of program design examined. For example, in terms of scope, the HRRP focuses exclusively on risk-standardized excess readmissions and the HACRP on patient safety. In contrast, HVBP includes 21 measures in five domains, including both quality and cost measures. Choices regarding penalties versus bonuses are similarly variable: HRRP and HACRP are penalty-only; HVBP, VM, and MIPS are penalty-or-bonus; and the MSSP and MA quality star rating programs are largely bonus-only. Each choice has distinct pros and cons that impact program efficacy. Unfortunately, there are scant data to inform which program design choice is best. While no one approach is clearly superior to another, the variability contained within these programs provides an important opportunity for Medicare and others to learn from these undertakings and to use that knowledge to inform future policymaking.

Changes in Hospital Quality Associated with Hospital Value-Based Purchasing

BackgroundStarting in fiscal year 2013, the Hospital Value-Based Purchasing (HVBP) program introduced quality performance–based adjustments of up to 1% to Medicare reimbursements for acute care hospitals.MethodsWe evaluated whether quality improved more in acute care hospitals that were exposed to HVBP than in control hospitals (Critical Access Hospitals, which were not exposed to HVBP). The measures of quality were composite measures of clinical process and patient experience (measured in units of standard deviations, with a value of 1 indicating performance that was 1 standard deviation [SD] above the hospital mean) and 30-day risk-standardized mortality among patients who were admitted to the hospital for acute myocardial infarction, heart failure, or pneumonia. The changes in quality measures after the introduction of HVBP were assessed for matched samples of acute care hospitals (the number of hospitals included in the analyses ranged from 1364 for mortality among patients admitted for acute myocardial infarction to 2615 for mortality among patients admitted for pneumonia) and control hospitals (number of hospitals ranged from 31 to 617). Matching was based on preintervention performance with regard to the quality measures. We evaluated performance over the first 4 years of HVBP.ResultsImprovements in clinical-process and patient-experience measures were not significantly greater among hospitals exposed to HVBP than among control hospitals, with difference-in-differences estimates of 0.079 SD (95% confidence interval [CI], −0.140 to 0.299) for clinical process and −0.092 SD (95% CI, −0.307 to 0.122) for patient experience. HVBP was not associated with significant reductions in mortality among patients who were admitted for acute myocardial infarction (difference-in-differences estimate, −0.282 percentage points [95% CI, −1.715 to 1.152]) or heart failure (−0.212 percentage points [95% CI, −0.532 to 0.108]), but it was associated with a significant reduction in mortality among patients who were admitted for pneumonia (−0.431 percentage points [95% CI, −0.714 to −0.148]).ConclusionsIn our study, HVBP was not associated with improvements in measures of clinical process or patient experience and was not associated with significant reductions in two of three mortality measures. (Funded by the National Institute on Aging.)

Innovative Health Care Financing Strategies for Children and Youth With Special Health Care Needs.

* Abbreviations: CYSHCN — : children and youth with special health care needs VBID — : value-based insurance design VBP — : value-based purchasing There is increasing interest in maximizing value in health care purchasing by promoting delivery and payment strategies that are cost-effective and also achieve optimal health outcomes. Although these strategies are often called value-based purchasing (VBP), no 1 shared definition of VBP exists. Damberg et al1 suggest that VBP includes a range of methods that link health care payment and incentives to provider performance. The Centers for Medicare and Medicaid Services has launched a Medicare hospital VBP program that rewards acute care hospitals with financial incentives for meeting specific performance outcomes.2 Payment reform provisions in the Affordable Care Act promote VBP strategies to achieve the Triple Aim of lower cost, increased efficiency, and improved population health.3 Value-based insurance design (VBID) is closely related to VBP. Chernew et al4 identified 2 basic approaches to VBID: reduced copayments for clinically valuable services in general; and reduced copayments for specific groups of patients who receive selected high-value services for specific diagnoses. Within this broad landscape of purchasing and insurance design strategies, other innovative financing approaches can promote the Triple Aim including bundled payments, accountable care organizations, and integrated care systems that link primary care and behavioral health services, among others. The impact of these strategies, especially on children and youth with special health care needs (CYSHCN), is currently unclear and, without careful planning, could present additional risk to an already vulnerable population of children. The issues involved in developing VBP for CYSCHN are critically important for this group of children who, by definition, use more health care services than other children and inevitably incur higher costs.5 Yet, organizing the incentives and payment structures appropriately could reward better care and outcomes also for CYSHCN. Working with the American Academy of Pediatrics, … Address correspondence to James M. Perrin, MD, 125 Nashua Street Boston, MA 02114. E-mail: jperrin{at}mgh.harvard.edu

Improving patients' pain experience in a large rural hospital.

The Hospital Value-Based Purchasing (HVBP) program was authorized by Congress in Section 3001 (a) of the Affordable Care Act. According to the Centers for Medicare and Medicaid Services (CMS), the HVBP program is part of the CMS effort to improve healthcare quality by focusing the payment structure