Value-Based Purchasing Program Research Articles

Trends in HCAHPS Survey Scores, 2008-2019: A Quality Improvement Perspective.

HCAHPS' 2008 initial public reporting, 2012 inclusion in the Hospital Value-Based Purchasing Program (HVBP), and 2015 inclusion in Hospital Star Ratings were intended to improve patient experiences. Characterize pre-COVID-19 (2008-2019) trends in hospital consumer assessment of healthcare providers and systems (HCAHPS) scores. Describe HCAHPS score trends overall, by phase: (1) initial public reporting period (2008-2013), (2) first 2 years of HVBP (2013-2015), and (3) initial HCAHPS Star Ratings reporting (2015-2019); and by hospital characteristics (HCAHPS decile, ownership, size, teaching affiliation, and urban/rural). A total of 3909 HCAHPS-participating US hospitals. HCAHPS summary score (HCAHPS-SS) and 9 measures. The mean 2007-2019 HCAHPS-SS improvement in most-positive-category ("top-box") responses was +5.2 percentage points/pp across all hospitals (where differences of 5pp, 3pp, and 1pp are "large," "medium," and "small"). Improvement rate was largest in phase 1 (+0.8/pp/year vs. +0.2pp/year and +0.1pp/year for phases 2 and 3, respectively). Improvement was largest for Overall Rating of Hospital (+8.5pp), Discharge Information (+7.3pp), and Nurse Communication (+6.5pp), smallest for Doctor Communication (+0.8pp). Some measures improved notably through phases 2 and 3 (Nurse Communication, Staff Responsiveness, Overall Rating of Hospital), but others slowed or reversed in Phase 3 (Communication about Medicines, Quietness). Bottom-decile hospitals improved more than other hospitals for all measures. All HCAHPS measures improved rapidly 2008-2013, especially among low-performing (bottom-decile) hospitals, narrowing the range of performance and improving scores overall. This initial improvement may reflect widespread, general quality improvement (QI) efforts in lower-performing hospitals. Subsequent slower improvement following the introduction of HVBP and Star Ratings may have reflected targeted, resource-intensive QI in higher-performing hospitals.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program

Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Hospital Value-Based Purchasing program HEA. Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults.

The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.

Increasing illness severity of skilled nursing facility patients over time: Implications for readmission penalties.

Current financial penalties for rehospitalization of skilled nursing facilities (SNFs) patients are based in part on the studies by Ouslander et al., 2011, and Mor et al., 2010, demonstrating that many SNF hospitalizations were avoidable. With increasing age, complex illness severity, and use of SNFs for subacute rehabilitation, readmission metrics and financial penalties based on previous data may be due for reevaluation. Retrospective electronic medical record (EMR) review of 21,591 admissions and discharges between 2010 and 2019 inclusive. Data extracted included demographics, LACE, Charlson comorbidity index (CCI), and simplified HOSPITAL score parameters. The scores were calculated for the study years from the extracted data. Patients readmitted to the hospital within 30 days were identified. Mean yearly score of all three indices rose steadily: LACE score 10.76-12.04 (0.43 estimated annual increase, 95% CI [0.39, 0.46]), CCI 4.26-5.05 (0.31 estimated annual increase, 95% CI [0.27, 0.34]), and simplified HOSPITAL score 3.46-4.03 (0.21 estimated annual increase, 95% CI [0.18, 0.24]). The estimated probability of readmission across observed CCI scores ranged from 15.4% to 15.9%, 95% CI bounds (10.8%, 22.7%). The estimated probability of readmission across observed LACE scores ranged from 4.7% to 36.3%, 95% CI bounds (3.4%, 54.7%). The estimated probability of readmission across observed HOSPITAL scores ranged from 5.8% to 54.1%, 95% CI bounds (6.2%, 66.0%). The study confirms anecdotal experience that the illness acuity of patients admitted to SNFs increased progressively over time and was associated with an increased risk of 30-day readmissions to the hospital. Our study suggests that the use of clinically validated readmission risk assessment tools instead of the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP) current risk adjustors may be a more accurate reflection of the current illness severity of a facility's patient population at the time of payment adjustment.

Hospital payment systems and physician reimbursement: A primer for radiology residents

Prior to practicing independently, radiology trainees spend considerable time and energy to learn and understand the practice of radiology. However, upon graduation trainees are often deficient in understanding the business of hospitals and the structure of reimbursement. Specifically, the workflow of relative value units (RVUs) and its impact on practice of radiology after completing training. In this manuscript, we provide a resource for trainees to understand the workflow of physician reimbursement. This article includes information on the mixed model healthcare structure of the United States and two government programs that influence reimbursement: Diagnosis-Related Groups (DRG) and Hospital Value-Based Purchasing (HVBP) programs. Furthermore, we explain the method by which the Center of Medicare and Medicate Service's (CMS) reimburses physicians via the Medicare Physician Fee Schedule (MPFS) using the Resource Based Relative Value Scale. Understanding the structure of these payments along with the challenges and current landscape of radiology reimbursement will help new radiologists prior to seeking employment where reimbursements are integral to contract expectations.

Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper.

The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.

Searching for the Best Yardstick: Cost of Quality Improvements in the U.S. Hospital Industry

The Hospital Value-Based Purchasing (VBP) Program is Medicare’s implementation of yardstick incentives applied to hospitals in the United States. Under the VBP Program, 2% of all Medicare payments to hospitals, estimated to be U.S. $1.9 billion in fiscal year 2021, are withheld and redistributed based on their relative performance in the quality of delivered care. We develop a dynamic mean-field equilibrium model in which hospitals are engaged in repeated competition under yardstick incentives. Using structural estimation methods, we recover key parameters that govern hospitals’ decisions to invest in quality improvement, including the financial and nonfinancial costs and uncertain outcomes of investment. By dynamically solving for hospitals’ individually optimal investment policies, we estimate the trajectory of quality improvements for each hospital, including its investment decisions and quality levels throughout the implementation of the VBP Program. Our counterfactual analyses explore the benefits, on the one hand, of modifying the overall size of the yardstick incentives and on the other hand, of implementing a more focused program tailored to hospital type. We find that increasing the size of the incentives from 2% to 4% would have resulted in an additional quality investment of U.S. $1.2 billion from 2011 to 2018, leading to a 3.3% reduction in the average rate of central line-associated bloodstream infections (CLABSIs). Applying yardstick incentives to the tailored hospital peer groups, even without changing the size of the incentives, can lead to an average reduction of 1.4% in the rate of CLABSI among groups of hospitals associated with the highest costs of quality investment. This paper was accepted by Stefan Scholtes, healthcare management. Funding: K. Moon acknowledges support from the Wharton School [Claude Marion Endowed Faculty Scholar Award]. Supplemental Material: The data files and online appendix are available at https://doi.org/10.1287/mnsc.2023.4875 .

The effect of patient quality measurements and HCAHPS patient satisfaction on hospital reimbursements

BACKGROUND: The Centers of Medicare & Medicaid Services (CMS) links hospital reimbursements to quality metrics. Likewise, the Hospital Value-Based Purchasing (VBP) program offers financial incentives to acute-care hospitals based on performance improvements on several quality measures included in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. A research gap exists with regard to assessing the effectiveness of VBP incentives on improving the patient’s quality of care. OBJECTIVE: This study is to determine whether hospitals which reported better patient quality metrics and lower frequency of pressure sores received higher reimbursements. METHODS: The data were retrieved from the CMS Care Compare website utilizing matched data from 2297 US hospitals. Information on HCAHPS, the VBP Program in Patient Safety Index, and Reimbursements was obtained for this study. Partial Least Square (PLS) was utilized thru SmartPLS 3.0 to test the hypotheses. RESULTS: The results did not reveal any financial penalties when hospitals reported lower patient quality outcomes and increased numbers of pressure sores. However, lower patient quality measures were associated with lower patient satisfaction. Controversially, lower patient satisfaction scores were associated with higher reimbursement rates overall. CONCLUSIONS: The main contribution of this study reveals that the effectiveness of value-based reimbursements and the concept of continuous improvement is constrained due to the lack of unified measurement objectives across US healthcare institutions.

Medicare Beneficiaries’ Perspectives on the Quality of Hospital Care and Their Implications for Value-Based Payment

Medicare's Hospital Value-Based Purchasing (HVBP) program adjusts hospital payments according to performance on 4 equally weighted quality domains: clinical outcomes, safety, patient experience, and efficiency. The assumption that performance on each domain is equally important may not reflect the preferences of Medicare beneficiaries. To estimate the relative importance (ie, weight) of the 4 quality domains in the HVBP program from the perspective of Medicare beneficiaries and the impact of using beneficiary value weights on incentive payments for hospitals enrolled in fiscal year 2019. An online survey was conducted in March 2022. A nationally representative sample of Medicare beneficiaries was recruited through Ipsos KnowledgePanel. Value weights were estimated using a discrete choice experiment that asked respondents to choose between 2 hospitals and indicate which they preferred. Hospitals were described using 6 attributes, including (1) clinical outcomes, (2) patient experience, (3) safety, (4) Medicare spending per patient, (5) distance, and (6) out-of-pocket cost. Data analysis was performed from April to November 2022. An effects-coded mixed logit regression model was used to estimate the relative importance of quality domains. HVBP program performance was linked to Medicare payment data in the Medicare Inpatient Hospitals by Provider and Service data set and hospital characteristics from the American Hospital Association Annual Survey data set, and the estimated impact of using beneficiary value weights on hospital payments was estimated. A total of 1025 Medicare beneficiaries (518 women [51%]; 879 individuals [86%] aged ≥65 years; 717 White individuals [70%]) responded to the survey. A hospital's performance on clinical outcomes was most highly valued by beneficiaries (49%), followed by safety (22%), patient experience (21%), and efficiency (8%). Nearly twice as many hospitals would see a payment reduction when using beneficiary value weights than would see an increase (1830 vs 922 hospitals); however, the average net decrease was smaller (mean [SD], -$46 978 [$71 211]; median [IQR], -$24 628 [-$53 507 to -$9562]) than the comparable increase (mean [SD], $93 243 [$190 654]; median [IQR], $35 358 [$9906 to $97 348]). Hospitals seeing a net reduction with beneficiary value weights were more likely to be smaller, lower volume, nonteaching, and non-safety-net hospitals located in more deprived areas that served less complex patients. This survey study of Medicare beneficiaries found that current HVBP program value weights do not reflect beneficiary preferences, suggesting that the use of beneficiary value weights may exacerbate disparities by rewarding larger, high-volume hospitals.

Moneyball in Medicare

One of the most important changes to the United States health care system over the last two decades is the emergence of pay-for-performance as a way to encourage hospitals and other providers to improve quality of care. Unlike fee-for-service, these value-based purchasing programs measure aspects of quality and financially reward hospitals that are outstanding or at least improving in their care. Prior research has shown that hospitals often improve more when the marginal financial incentives are larger. However, the exact relationship between marginal financial incentives and year-over-year improvement in measures remains unclear. In this study, we use national 20152018 data on approximately 2,700 hospitals to estimate how hospitals respond to pay-for-performance incentives in the Hospital Value-Based Purchasing (HVBP) Program. We show that this relationship is non-linear, has strong serial correlation, is somewhat similar for safety-net hospitals as non-safety-net hospitals, and is proportional to the size of the Medicare patient population.

Coaching to Bedside Shift Report and Its Correlation to Hospital Consumer Assessment of Healthcare Providers and Systems and Value-Based Purchasing Dimension Scores

The objective of this multihospital study was to investigate how the intervention of coaching to bedside shift report (BSR) correlates with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) outcomes and relates to Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (VBP) Program points over a 4-year period (2017-2020) for an acute care hospital health system. Hospital leaders' responsibilities include intertwined areas of patient experience and fiscal accountability. Coaching to BSR is reported to have numerous benefits to the patient's experience. Published studies completed with hospital systems evaluating the intervention of coaching to BSR and how it correlated to patient experience and VBP are limited. Coaching to BSR was implemented at 16 adult acute care hospitals. Patient-reported BSR rates were collected in tandem with HCAHPS for 4 years. Statistical correlations were assessed between patient-reported BSR and HCAHPS and consequential effect on VBP dimension scores. Coaching to BSR had a significant impact on top- and bottom-box "rate the hospital" HCAHPS scores at a system and hospital level. Value-based purchasing points and percentages increased over 2017-2020, potentially leading to lower CMS penalty claims over the period the BSR was implemented. Coaching is a key factor when creating a favorable patient experience. The implementation and sustainability of coaching to BSR may result in improved patient experience ratings and increase VBP point accumulation to hospital systems.

Measuring the State Dependence Effect in Hospital Payment Adjustment.

Since FY 2013, as a part of the Affordable Care Act (ACA) program, the Hospital Value-Based Purchasing (HVBP) program has adjusted Medicare's payments to hospitals based on the total performance score of the hospital. First, the program reduces a portion of the hospital's Medicare payments in a specific fiscal year, and then, by the end of the same fiscal year, the amount of the payment reductions will be awarded to the hospitals based on the total performance score; thus, the hospitals that do not receive the reward will lose the portion of money reduced by Medicare. In this research, we apply the theory of state dependence and use the dynamic random effect probit model to estimate this effect. The results show that the hospital payment adjustment dynamics have a very significant state dependence effect (0.341); this means that hospitals that received a reward in the previous year are 34.1% more likely to receive a reward this year than the ones that received a penalty in the previous year. Meanwhile, we also find that the state dependence effect varies significantly across hospitals with different ownership (proprietary/government owned/voluntary nonprofit), and the results show that voluntary nonprofit hospitals exhibit the largest effect of state dependence (0.370), while government-owned hospitals exhibit the lowest effect of state dependence (0.293), and proprietary hospitals are in the middle. Among the factors that influence the likelihood that a hospital receives a reward, we find that teaching hospitals with a large number of beds (>400) are less likely be rewarded; in terms of ownership, we find that voluntary nonprofit hospitals are more likely be rewarded; in terms of demographic factors, hospitals where the average household income are higher within the region are more likely be rewarded.

Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives.

Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.

The role of community-level characteristics in comparing United States hospital performance by magnet designation: A propensity score matched study.

To assess the impact of community-level characteristics on the role of magnet designation in relation to hospital value-based purchasing quality scores, as health disparities associated with geographical location could confound hospitals' ability to meet outcome metrics. This cross-sectional study was carried out between October 2021 and March 2022 using data from 2016 to 2021. Propensity score analysis was used to match hospital and community-level characteristics, implementing nearest neighbour matching to adjust for pre-treatment differences between magnet and non-magnet hospitals to account for multi-level differences. Secondary data were obtained from all operational acute-care facilities in the United States that participated in the Centers for Medicare and Medicaid Services' hospital value-based purchasing (HVBP) program. Dependent variables were the four value-based purchasing domains that comprise the Total Performance Score (TPS; Clinical Care, Person and Community Engagement, Safety, and Efficiency and Cost Reduction). Magnet hospitals had increased odds for better scores in the HVBP domains of Clinical Care and Person and Community Engagement, and decreased odds for having better Safety. However, no statistically significant difference was found for the Efficiency domain or the TPS. Measuring performance equitably across organizations of various sizes serving diverse communities remains a key factor in ensuring distributive justice. Analysing the TPS components can identify complex influences of community-level characteristics not evident at the composite level. More research is needed where community and nurse-level factors may indirectly affect patient safety. This study's findings on the role of community contexts can inform policymakers designing value-based care programs and healthcare management administrators deliberating on magnet certification investments across diverse community settings. For this study of US hospitals' organizational performance, we did not engage members of the patient population nor the general public. However, the multi-disciplinary research team does include diverse perspectives.

Value-Based Payments in Health Care: Evidence from a Nationwide Randomized Experiment in the Home Health Sector.

Value-based payment programs, also known as pay-for-performance, use financial incentives to motivate providers to invest in quality and are a critical part of Medicare health care reform. This study examines the first year of the Home Health Value-Based Purchasing program, a nationally representative cluster randomized experiment implemented by the Centers for Medicare & Medicaid Services in 2016. The goal of the program is to achieve better home health care quality. Home health agencies in treatment states were rewarded or penalized based on their performance on agency-reported and non-agency-reported quality measures. The program improved agency-reported measures by approximately one percentage point, and performance gains suggest a dose-response relationship with respect to incentive size. However, the performance gains in agency-reported measures did not reflect true quality improvement. I find evidence that agencies manipulated their coding of patients and inflated their performance. Coding manipulation explains the entirety of the program's impact on agency-reported measures.

The Role of Social Risk Factors in Dialysis Quality and Patient Outcomes Under a Medicare Quality Incentive Program.

There have been critical improvements in dialysis care and mortality in the last decade. These improvements track with the implementation of the end-stage renal disease (ESRD) Quality Incentive Program (QIP) beginning in 2012, which aligns Medicare payments to dialysis facilities with performance on quality measures. This study explores whether the improvements in dialysis care and patient outcomes under the ESRD QIP have been shared equally among patient groups. Our analyses focus on 4 social risk factors: Black race, Hispanic ethnicity, dual eligibility for Medicare and Medicaid, and rurality. We estimated multivariable regressions using longitudinal Medicare and Consolidated Renal Operations in a Web-Enabled Network data. ESRD QIP payment reductions were more common at dialysis facilities with higher proportions of Black and dual-eligible ESRD patients. Patients with dual eligibility and Black race had persistently worse relative outcomes as the ESRD QIP was implemented. This finding was true for differences in outcomes when comparing patients within and across facilities and was not affected by the addition of specific quality measures to the ESRD QIP measure set. Hispanic patients and patients at rural facilities have generally not had worse outcomes since the start of the ESRD QIP. There is no evidence of widening disparities in dialysis care or patient outcomes across patient groups under the ESRD QIP, which is a longstanding and well-publicized concern with value-based purchasing programs. Relative changes between patient groups since the start of ESRD QIP have not favored any patient group. Many disparities in dialysis quality measures and assessment of dialysis facility payment reductions persist.

Association of the Medicare Value-Based Purchasing Program With Changes in Patient Care Experience at Safety-net vs Non–Safety-net Hospitals

Safety-net hospitals, which have limited financial resources and care for disadvantaged populations, have lower performance on measures of patient experience than non-safety-net hospitals. In 2011, the Centers for Medicare & Medicaid Services Hospital Value-Based Purchasing (VBP) program began tying hospital payments to patient-reported experience scores, but whether implementation of this program narrowed differences in scores between safety-net and non-safety-net hospitals is unknown. To evaluate whether the VBP program's implementation was associated with changes in measures of patient-reported experience at safety-net hospitals compared with non-safety-net hospitals between 2008 and 2019. This cohort study evaluated 2266 US hospitals that participated in the VBP program between 2008 and 2019. Safety-net hospitals were defined as those in the highest quartile of the disproportionate share hospital index. Data were analyzed from December 2021 to February 2022. The primary outcomes were the Hospital Consumer Assessment of Healthcare Providers and Systems global measures of patient-reported experience and satisfaction, including a patient's overall rating of a hospital and willingness to recommend a hospital. Secondary outcomes included the 7 other Hospital Consumer Assessment of Healthcare Providers and Systems measures encompassing communication ratings, clinical processes ratings, and hospital environment ratings. Piecewise linear mixed regression models were used to assess annual trends in performance on each patient experience measure by hospital safety-net status before (July 1, 2007-June 30, 2011) and after (July 1, 2011-June 30, 2019) implementation of the VBP program. Of 2266 US hospitals, 549 (24.2%) were safety-net hospitals. Safety-net hospitals were more likely than non-safety-net hospitals to be nonteaching (67.6% [371 of 549] vs 53.1% [912 of 1717]; P < .001) and urban (82.5% [453 of 549] vs 77.4% [1329 of 1717]; P = .01). Safety-net hospitals consistently had lower patient experience scores than non-safety-net hospitals across all measures from 2008 to 2019. The percentage of patients rating safety-net hospitals as a 9 or 10 out of 10 increased during the pre-VBP program period (annual percentage change, 1.84%; 95% CI, 1.73%-1.96%) and at a slower rate after VBP program implementation (annual percentage change, 0.49%; 95% CI, 0.45%-0.53%) at safety-net hospitals. Similar patterns were observed at non-safety-net hospitals (pre-VBP program annual percentage change, 1.84% [95% CI, 1.77%-1.90%] and post-VBP program annual percentage change, 0.42% [95% CI, 0.41%-0.45%]). There was no differential change in performance between these sites after the VBP program implementation (adjusted differential change, 0.07% [95% CI, -0.08% to 0.23%]; P = .36). These patterns were similar for the global measure that assessed whether patients would definitely recommend a hospital. There was also no differential change in performance between safety-net and non-safety-net hospitals under the VBP program across measures of communication, including doctor (adjusted differential change, -0.09% [95% CI, -0.19% to 0.01%]; P = .08) and nurse (adjusted differential change, -0.01% [95% CI, -0.12% to 0.10%]; P = .86) communication as well as clinical process measures (staff responsiveness adjusted differential change, 0.13% [95% CI, -0.03% to 0.29%]; P = .11; and discharge instructions adjusted differential change, -0.02% [95% CI, -0.12% to 0.07%]; P = .62). This cohort study of 2266 US hospitals found that the VBP program was not associated with improved patient experience at safety-net hospitals vs non-safety-net hospitals during an 8-year period. Policy makers may need to explore other strategies to address ongoing differences in patient experience and satisfaction, including additional support for safety-net hospitals.

The Hospital Value-Based Purchasing Program: Do hospitalists improve health care value.

As healthcare organizations examine the associated benefits of employing a larger hospitalist workforce, there is a need to better understand the association with patients' quality, experience, and efficiency. However, there is a lack of information regarding how hospital use of hospitalists over time influences hospital scoring on quality programs, such as the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Value-Based Purchasing (HVBP) Program. This study examines the association between hospitalist staffing between 2014 and 2019 and HVBP scores. We used a cross-sectional panel study design. Total Performance Score (TPS) and its domains were obtained from CMS from 2014 to 2019 and merged with the American Hospital AssociationAnnual Survey Database. We utilized random-effects multivariable panel regression models and zero-inflated negative binomial regression to examine the association between the hospitalist-staffing ratio and the HVBP Program. All models were adjusted for hospital characteristics. A total of 2126 hospitals were included in the study. The average ratio of hospitalists per staffed bed was 0.06, with a standard deviation of 0.15. This study suggests that hospitals that employ a higher percentage of hospitalists see improvement in their overall TPS (β = 5.40; p < .001), Patient Experience (β = 2.49; p <.05), andEfficiency (incidence-rate ratio= 1.41; p < .001) domain. However, the Clinical Care domain was no different in organizations employing more hospitalists. There are benefits associated with TPS, Patient Experience, and Efficiency from employing hospitalists. Managers should seek opportunities to leverage hospitalists' expertise in providing care, particularly in improving care processes.

Is the Hospital Value-Based Purchasing Program Associated with Reduced Hospital Readmissions?

IntroductionHospital readmissions have been associated with adverse outcomes and elevated financial costs to patients, families, and hospitals across the United States. Historically, nearly 20% of all Medicare discharges had a readmission within 30 days. In an effort to address this issue, the Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012 to positively influence readmissions associated with acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and total hip and/or knee arthroplasty. However, as recently as 2018, there were still 3.8 million 30-day all-cause adult hospital readmissions, with a 14% readmission rate and an average readmission cost of $15,200. The ACA also produced the Hospital Value-Based Purchasing (HVBP) program with the stated intent to (1) reduce mortality and complications, (2) reduce healthcare-associated infections, (3) increase patient safety, (4) improve the patient experience, and (5) increase efficiency and reduce costs. Given the costs and quality implications of an average readmission, it is logical to believe that HVBP eligible hospitals are simultaneously seeking to meet the goals of both programs. However, to date, no studies have examined if that is the case. Thus, in this study, we seek to determine if HVBP eligible hospitals are associated with a reduction in the core set of HRRP readmission rates better than the facilities that are not eligible for the HVBP program.MethodsHospital-level data from calendar year 2019 for 3,276 short-term acute care hospitals in the United States were evaluated using multivariate regression analysis to examine the readmission rate performance between 2,719 HVBP eligible hospitals and 557 ineligible hospitals.ResultsOur six separate multivariable linear regressions revealed a statistically significant and positive association between HVBP participation and readmission rates after controlling for numerous organizational, clinical complexity, and environmental factors. In each case, the magnitude of the positive directional association is moderate, ranging from and increase of +0.19% (pneumonia readmissions) to as high as +0.37% (all cause readmissions) for HVBP eligible hospitals. When considered in the context of the average number of discharges in our data set (x- = 9570), a third of a percent increase from the average 15.56% all cause readmissions to 16.08% in HVBP eligible hospitals equates to 50 additional readmissions annually (9570 × 15.56% = 1,489 vs 9570 × 16.08% = 1,539). At an average cost of $15,200 per readmission, which equates to an average additional cost to the average HVBP eligible hospital in excess of $760,000.DiscussionThe fact that there is a positive association between HVBP participating hospitals and readmissions at all, and that the same effect appears to be persistent across all dependent measures is concerning. One would logically expect hospitals that are focused on quality-based care to thoroughly care for individuals in order for them to not be readmitted to the hospital. The results provided do not necessarily prove that either program is not working. But they also do not confirm that the HVBP and HRRP programs are working together and accomplishing what they were originally designed to do: improve patient care and lower health-care costs.

A Season for PALTC: Improving Quality, Increasing Transparency, and Strengthening Our Workforce

Just a few weeks before assuming the role of president of AMDA – The Society for Post-Acute and Long-Term Care Medicine, I sat on the sofa in my family room watching President Biden give the State of the Union address. During the speech, he announced his administration’s exciting plan to improve quality and safety in nursing homes. The plan includes five pillars that target ensuring safe, adequate, and dignified care; enhancing accountability and oversight; increasing transparency; strengthening the workforce; and ensuring pandemic and emergency preparedness.Not since the Omnibus Reconciliation Act of 1987 has there been such a significant commitment to improving nursing home care. Many will need to gather and use their collective knowledge and experiences to effectively reimagine nursing home care. The Society and its members can play a vital role in this process. This work will be a focus of the year ahead.At its core, the president’s plan aligns with the Society’s vision of “a world in which all post-acute and long-term care (PALTC) patients and residents receive the highest quality, compassionate care for optimum health, function and quality of life” and illuminates concepts that the Society has worked to advance for decades. We have and will support bold actions to improve quality of care and life for residents, including initiatives like single occupancy rooms and full-time infection preventionists. Strengthening value-based purchasing programs in a way that aligns excellence in care with better reimbursement can be informed by the Society’s work to understand and measure quality of care.As safeguards against unnecessary medications and treatments are explored, the Society has a strong legacy of provider engagement and expertise in the care of the psychological and behavioral symptoms that drive prescribing in the nursing home. Calling upon the success of our recent initiative “Drive to Deprescribe,” a program that enrolled over 4,500 nursing homes, we also can move the conversation beyond antipsychotics to other opportunities for improved prescribing in PALTC.Transparency in nursing homes is essential to ensuring accountability to quality of care. Developing a database of owners and operators is an important step, but it should be expanded to also include facility clinical leadership. The Society has long advocated for a registry of medical directors of certified nursing facilities. When concerns arise, residents and families should have no barriers to identifying those accountable for medical care processes and staff. Similarly, during emergencies like the COVID-19 pandemic, public health entities should be able to readily communicate with these leaders regarding infection prevention directives, diagnostics, and therapeutics. Regulations require medical directors in nursing facilities; we all should expect them to be engaged.Perhaps the most important work during this season will target strengthening the PALTC workforce. To that end, the Society’s Board of Directors recently convened a Workforce Development Committee that will review our work to date, complete a gap analysis, and help determine the roles we take in the months and years ahead.Central to a strong workforce is training for nursing home medical directors. California recently passed legislation requiring certification for nursing home medical directors, and our state policy advocates are encouraging other states to make similar commitments. The Core Curriculum on Medical Direction has recently been redesigned and is a ready resource.Similarly, we cannot ensure quality care without medical providers who have met the competencies for the special practice of PALTC medicine. The Society has a massive library of education materials and clinical practice tools (see https://bit.ly/3L2Mir4). In the months ahead, the Society will be working to ensure more clinical practice guidelines and tools are revisized so they are easily disseminated and used by professionals at the bedside. For example, our most recent pocket guide, “Parkinson’s Disease and Psychosis in the PALTC Setting,” is freely available on the AMDA App (or you can find it here: https://bit.ly/3D3CQkD). Our latest clinical practice guideline, focused on pain management in the PALTC setting, has been published in JAMDA (J Am Med Dir Assoc 2021;22:2407) and is available on the Society’s website (https://bit.ly/3uksPLS).To have a strong nursing home workforce, we also need to attract the next generation of medical professionals to our work. My own path toward practice in the nursing home illustrates how I was guided on just such a journey. During my graduate medical education, I was given the opportunity to spend time with nursing home residents and the interdisciplinary teams who cared for them. The physicians and other members of the interdisciplinary team welcomed me and other learners into their setting, and they showed us the complex art and science used in their work. The U.S. Health Resources & Services Administration (HRSA) Geriatrics Academic Career Award supported my time so that I could further kindle my interest in improving nursing home care. A Society member nominated me for the Foundation Futures program, and as a Futures participant I was gifted with inspiration, enhanced learning, and a community in which I could continue to develop.Each of these steps continued my journey, leading me to the roles of medical director and PALTC specialist, and eventually to becoming this year’s Society president. To sustain our workforce, we need to both invest in paths like mine and build innovative new routes to careers in long-term care.We are in a season of unprecedented interest in nursing home care, and I am grateful to have the privilege of working with the incredibly intelligent and compassionate leaders of the Society. They inspire me, and together our work is making a real difference in people’s lives. As I think about the next year, I am excited to see how many steps we will take toward achieving our mission.Dr. Gillespie is president of AMDA – The Society for Post-Acute and Long-Term Care. She lives in Rochester, New York, where she is associate professor of medicine at the University of Rochester School of Medicine and Dentistry. Just a few weeks before assuming the role of president of AMDA – The Society for Post-Acute and Long-Term Care Medicine, I sat on the sofa in my family room watching President Biden give the State of the Union address. During the speech, he announced his administration’s exciting plan to improve quality and safety in nursing homes. The plan includes five pillars that target ensuring safe, adequate, and dignified care; enhancing accountability and oversight; increasing transparency; strengthening the workforce; and ensuring pandemic and emergency preparedness. Not since the Omnibus Reconciliation Act of 1987 has there been such a significant commitment to improving nursing home care. Many will need to gather and use their collective knowledge and experiences to effectively reimagine nursing home care. The Society and its members can play a vital role in this process. This work will be a focus of the year ahead. At its core, the president’s plan aligns with the Society’s vision of “a world in which all post-acute and long-term care (PALTC) patients and residents receive the highest quality, compassionate care for optimum health, function and quality of life” and illuminates concepts that the Society has worked to advance for decades. We have and will support bold actions to improve quality of care and life for residents, including initiatives like single occupancy rooms and full-time infection preventionists. Strengthening value-based purchasing programs in a way that aligns excellence in care with better reimbursement can be informed by the Society’s work to understand and measure quality of care. As safeguards against unnecessary medications and treatments are explored, the Society has a strong legacy of provider engagement and expertise in the care of the psychological and behavioral symptoms that drive prescribing in the nursing home. Calling upon the success of our recent initiative “Drive to Deprescribe,” a program that enrolled over 4,500 nursing homes, we also can move the conversation beyond antipsychotics to other opportunities for improved prescribing in PALTC. Transparency in nursing homes is essential to ensuring accountability to quality of care. Developing a database of owners and operators is an important step, but it should be expanded to also include facility clinical leadership. The Society has long advocated for a registry of medical directors of certified nursing facilities. When concerns arise, residents and families should have no barriers to identifying those accountable for medical care processes and staff. Similarly, during emergencies like the COVID-19 pandemic, public health entities should be able to readily communicate with these leaders regarding infection prevention directives, diagnostics, and therapeutics. Regulations require medical directors in nursing facilities; we all should expect them to be engaged. Perhaps the most important work during this season will target strengthening the PALTC workforce. To that end, the Society’s Board of Directors recently convened a Workforce Development Committee that will review our work to date, complete a gap analysis, and help determine the roles we take in the months and years ahead. Central to a strong workforce is training for nursing home medical directors. California recently passed legislation requiring certification for nursing home medical directors, and our state policy advocates are encouraging other states to make similar commitments. The Core Curriculum on Medical Direction has recently been redesigned and is a ready resource. Similarly, we cannot ensure quality care without medical providers who have met the competencies for the special practice of PALTC medicine. The Society has a massive library of education materials and clinical practice tools (see https://bit.ly/3L2Mir4). In the months ahead, the Society will be working to ensure more clinical practice guidelines and tools are revisized so they are easily disseminated and used by professionals at the bedside. For example, our most recent pocket guide, “Parkinson’s Disease and Psychosis in the PALTC Setting,” is freely available on the AMDA App (or you can find it here: https://bit.ly/3D3CQkD). Our latest clinical practice guideline, focused on pain management in the PALTC setting, has been published in JAMDA (J Am Med Dir Assoc 2021;22:2407) and is available on the Society’s website (https://bit.ly/3uksPLS). To have a strong nursing home workforce, we also need to attract the next generation of medical professionals to our work. My own path toward practice in the nursing home illustrates how I was guided on just such a journey. During my graduate medical education, I was given the opportunity to spend time with nursing home residents and the interdisciplinary teams who cared for them. The physicians and other members of the interdisciplinary team welcomed me and other learners into their setting, and they showed us the complex art and science used in their work. The U.S. Health Resources & Services Administration (HRSA) Geriatrics Academic Career Award supported my time so that I could further kindle my interest in improving nursing home care. A Society member nominated me for the Foundation Futures program, and as a Futures participant I was gifted with inspiration, enhanced learning, and a community in which I could continue to develop. Each of these steps continued my journey, leading me to the roles of medical director and PALTC specialist, and eventually to becoming this year’s Society president. To sustain our workforce, we need to both invest in paths like mine and build innovative new routes to careers in long-term care. We are in a season of unprecedented interest in nursing home care, and I am grateful to have the privilege of working with the incredibly intelligent and compassionate leaders of the Society. They inspire me, and together our work is making a real difference in people’s lives. As I think about the next year, I am excited to see how many steps we will take toward achieving our mission. Dr. Gillespie is president of AMDA – The Society for Post-Acute and Long-Term Care. She lives in Rochester, New York, where she is associate professor of medicine at the University of Rochester School of Medicine and Dentistry.