Hospital Value-Based Purchasing Program Research Articles

A Novel Approach to Improving Patient Experience in Orthopedics.

The patient experience domain comprises a significant portion of the Hospital Value-Based Purchasing program. This study investigated whether an intervention focusing on attending physician awareness, resident and physician assistant education, and multidisciplinary patient-centric care had an effect on patient perceived physician communication and overall hospital ratings. Responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey were reviewed in 2014 and 2015. Patients' perceptions that the physician explained their condition in ways they understood and the overall hospital rating improved significantly after implantation of the model ( P < .05). Patient-physician communication is important for high-quality health care and is becoming increasingly more important in hospital economics. These methods may serve as a protocol for other institutions to improve the patient experience.

Impact of Provider Incentives on Quality and Value of Health Care

The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.

Understanding The Role Played By Medicare's Patient Experience Points System In Hospital Reimbursement.

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4billion in performance-based incentives; 30percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p= 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals.

Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study

Objective To determine the impact of the Hospital Value-Based Purchasing (HVBP) program—the US pay for performance program introduced by Medicare to incentivize higher quality care—on 30 day mortality for three...

Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals.

In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0percent in fiscal year 2014 compared to 17percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.

Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk

There is little to no improvement in the quality of patient care since the publication of To Err Is Human report in 1999 by the Institute of Medicine. Health care provider education must address quality and patient safety language in order to meet the demands of the 21st century. Academic institutions focus on the quality and safety language as outlined by the Quality and Safety Education for Nurses (QSEN). Conversely, hospitals emphasize competencies and standards as outlined in The Joint Commission accreditation standards and the American Nurses Credentialing Center Magnet® competencies. Nurse leaders need a crosswalk among all 3 standards that can help guide their practice. The crosswalk can help nurse leaders have an increased understanding of the role that QSEN plays in educating a competent and safe nursing workforce.

Centralizing Value: An Institutional Theory Perspective

The implementation of the Hospital Value-Based Purchasing (HVBP) program through the Centers for Medicare and Medicaid has provided hospitals with new environmental pressures relating to quality, p...

Association of Postdischarge Spending and Performance on New Episode-Based Spending Measure.

The Centers for Medicare & Medicaid Services (CMS) is incentivizing hospitals to provide high-quality, low-cost care.1 As part of these efforts, CMS recently added the Medicare-Spending-per-Beneficiary (MSPB) metric to its Hospital Value-Based Purchasing (HVBP) program, marking the first time that most US hospitals have received financial penalties or rewards based on their performance on a risk-adjusted, price-standardized 30-day episode-based measure of Medicare spending along with quality measures. It is not yet known how hospitals can do well on this new spending measure. We examined whether hospitals that performed poorly (or well) did so because of spending before, during, or after hospitalization.

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Impact of Nurse Certification Rates on Patient Satisfaction and Outcomes: A Literature Review.

The Institute of Medicine's report The Future of Nursing: Leading Change, Advancing Health states that continued competence requires lifelong learning. Certification measures lifelong learning by validating the expertise of nurses in specialty areas beyond those required by licensure examinations. Current research provides limited quantitative evidence to support a positive correlation between nurse certification rates and patient satisfaction and outcomes. The health care industry and affiliated professionals are experiencing increased public scrutiny and accountability through mandated quality of care measures that impact monetary reimbursement. Increased public scrutiny and accountability highlights the need for research to substantiate the quantitative benefits of nurse certification on patient satisfaction and outcomes. The Hospital Consumer Assessment of Healthcare Providers and Systems Survey scores, the Hospital Value-Based Purchasing program, and the National Database of Nursing Quality Indicators(®) are potential sources for producing the reliable and valid evidence needed to convince RNs, hospital administrators, and all other stakeholders that nurse certification has a quantifiable correlation with patient satisfaction and outcomes.

Nurse Bullying: A Review And A Proposed Solution

Nurse bullying is an extremely common phenomenon which has detrimental consequences to nurses, patients, health care institutions, and to the nursing profession itself. It has even been linked to increased patient mortality. This article demonstrates the critical need to resolve the issue of nurse bullying. It also shows that previous attempts of resolution have not been successful, which may be partly due to the fact that the problem is relatively unacknowledged outside the nursing profession. To resolve the problem of nurse bullying, we believe that the solution must include an incentive for institutions to implement the necessary interventions and to ensure that they are effective. We propose that a measurement pertaining to the level of nurse bullying be factored into the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program. To facilitate this, we propose that a survey be developed and implemented which is similar to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. However, whereas the HCAHPS survey measures patients' perspectives of hospital care, this survey would measure nurses' perspectives of workplace bullying.

Implementing a Pain Care Toolkit to Improve Patient Perception of Pain Care.

As a result of the Hospital Value-Based Purchasing (VBP) Program, hospitals are now faced with reimbursement for quality of care, including patient perception of care, as measured by the Hospital Compare Assessment of Health Plans Survey, which includes the patient experience with pain care. Through the implementation of a Pain Care Quality Toolkit, patient perception of pain care can be improved, thus increasing the possibility of maximum reimbursement through the VBP.

The Relationship Between Hospital Value-Based Purchasing Program Scores and Hospital Bond Ratings

Tax-exempt hospitals and health systems often borrow long-term debt to fund capital investments. Lenders use bond ratings as a standard metric to assess whether to lend funds to a hospital. Credit rating agencies have historically relied on financial performance measures and a hospital's ability to service debt obligations to determine bond ratings. With the growth in pay-for-performance-based reimbursement models, rating agencies are expanding their hospital bond rating criteria to include hospital utilization and value-based purchasing (VBP) measures. In this study, we evaluated the relationship between the Hospital VBP domains--Clinical Process of Care, Patient Experience of Care, Outcome, and Medicare Spending per Beneficiary (MSPB)--and hospital bond ratings. Given the historical focus on financial performance, we hypothesized that hospital bond ratings are not associated with any of the Hospital VBP domains. This was a retrospective, cross-sectional study of all hospitals that were rated by Moody's for fiscal year 2012 and participated in the Centers for Medicare & Medicaid Services' VBP program as of January 2014 (N = 285). Of the 285 hospitals in the study, 15% had been assigned a bond rating of Aa, and 46% had been assigned an A rating. Using a binary logistic regression model, we found an association between MSPB only and bond ratings, after controlling for other VBP and financial performance scores; however, MSPB did not improve the overall predictive accuracy of the model. Inclusion of VBP scores in the methodology used to determine hospital bond ratings is likely to affect hospital bond ratings in the near term.

PRACTITIONER APPLICATION: The Relationship Between Hospital Value-Based Purchasing Program Scores and Hospital Bond Ratings

PRACTITIONER APPLICATION: The Relationship Between Hospital Value-Based Purchasing Program Scores and Hospital Bond Ratings

Value-Based Purchasing, Efficiency, and Hospital Performance

The Medicare hospital value-based purchasing (HVBP) program that links Medicare payments to quality of care became effective in 2013 in the United States. Hospital efficiency will be added to the HVBP in 2015. It is unclear whether hospital efficiency-specific hospital characteristics are associated with HVBP performance scores and the subsequent incentive payments. Using data from the American Hospital Association Annual Survey the Medicare Hospital Compare, this article examines the association of hospital efficiency hospital characteristics with the HVBP performance scores. The results indicate that less efficient hospitals are more likely to have lower patient satisfaction scores and total performance scores compared with more efficient hospitals. Hospital size, ownership, and payer mix also have significant impact on HVBP performance scores. The findings of this study provide significant policy practice implications. On the one hand, hospitals should consider investing their limited resources into identifying implementing the most cost-effective procedures to improve their patient experience total performance scores. On the other hand, policymakers should consider the unintended negative impact that these new payment incentives will likely have on hospitals that serve a higher proportion of low-income racial ethnic minority populations.

Spending Medicare’s Dollars Wisely: Taking Aim at Hospitals’ Cultures of Overtreatment

With Medicare’s rising costs threatening the country’s fiscal health, policymakers have focused their attention on a primary cause of Medicare’s high price tag—the overtreatment of patients. Guided by professional norms that demand they do “everything possible” for their patients, physicians frequently order additional diagnostic tests, perform more procedures, utilize costly technologies, and provide more inpatient care. Much of this care, however, does not improve Medicare patients’ health, but only increases Medicare spending. Reducing the overtreatment of patients requires aligning physicians’ interests with the government’s goal of spending Medicare’s dollars wisely. Toward that end, recent Medicare payment reforms establish a range of financial incentives that encourage more efficient practices among physicians. Physicians, however, do not practice medicine in a vaccum. Rather, they are profoundly influenced by the organizational cultures of hospitals. Far too often hospitals’ cultures lead physicians to provide Medicare patients care of questionable value. If Medicare is to successfully contain costs, it must prod hospitals to move from cultures of overtreatment to cultures of efficiency. Current Medicare reform proposals, however, do too little to address hospitals’ cultures of overtreatment. That is unfortunate, as regulators will have limited success in constraining Medicare’s growth if hospitals’ cultures continue to foster the overtreatment of Medicare patients. This Article therefore sets forth a more robust proposal for reforming Medicare payment policy, one that would facilitate hospitals fully embracing a culture of efficiency. Specifically, federal regulators should reform the Medicare Hospital Value-Based Purchasing Program so that a hospital’s Medicare payment rates are tied to the hospital’s success in lowering the cost of treating patients both inside and outside the hospital setting. Regulators could accomplish this goal by incorporating into the program efficiency measures based on broadly defined episodes of care.

Is There a Relationship Between Value-Based Purchasing and Hospital Profitability? An Exploratory Study of Missouri Hospitals.

Recent US legislation is attempting to transition inpatient Medicare payments to a value-based purchasing (VBP) program. The VBP program is a pay-for-performance (P4P) system that incentivizes hospitals to improve patient satisfaction, health outcomes, and adherence to clinical protocols while simultaneously holding down costs. Our study evaluates (1) the impact of financial performance on the VBP adjustments and (2) whether there is a correlation between the VBP adjustment and the financial performance of Missouri hospitals that opted into the program. While upward and downward adjustments to the inpatient base rate may be related to hospital financial performance, prior financial performance may also be related to the adjustments. Financial health may allow facilities to invest and position the hospital for favorable future P4P adjustments. The results of our analysis indicate the VBP adjustment to the inpatient base rate is very small (±0.18%), clustered around zero, and is not correlated with financial performance. We also find that financial performance and improvement in the years prior to the adjustment are not related to the VBP adjustment or its respective components. This suggests that CMS is avoiding penalizing less profitable facilities, but the adjustment is also so small and tightly clustered around zero that it is failing to provide an adequate incentive to hospitals. The costs of improving patient satisfaction, clinical process adherence, health care outcomes, and efficiency above that of peers coupled with the growing number of metrics being used to calculate the VBP adjustments call into question the financial incentives of the hospital VBP program.

A cross-sectional study of emergency department boarding practices in the United States.

The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

Beyond ACOs and Bundled Payments

For all the attention paid to accountable care models, few observers have recognized that Medicare is rolling out the core framework of bundled payments within the hospital fee-for-service payment system. Under its hospital value-based purchasing (HVBP) program, Medicare has established the Medicare Spending Per Beneficiary (MSPB) metric, defined as the average Medicare Part A and Part B spending per patient (eg, all traditional Medicare fee-for-service spending outside of prescription drug coverage) from 3 days prior to admission to 30 days after discharge. Hospital value-based purchasing adjusts each hospital’s fee-for-service Medicare reimbursement based on various performance benchmarks, such as MSPB; more than 1400 hospitals will receive reductions in their Medicare payment rates this year.1 Although Medicare has created a number of pay-for-performance programs over the past decade, MSPB represents the first pay-for-efficiency measure embedded within the fee-for-service system to penalize or reward hospitals not just for readmission rates or efficiency within an inpatient stay but for the value of care delivered across the entire continuum.