Value-based Purchasing Research Articles

Hospital value-based purchasing, market competition, and outpatient imaging efficiency

Background: The Centers for Medicare & Medicaid Services (CMS) collects data on hospital outpatient imaging efficiency (OIE) to reduce unnecessary exposure to contrast materials and prevent wasteful use of Medicare resources. In 2013, CMS implemented the Inpatient Hospital Value-Based Purchasing Program to improve quality and efficiency. There has been no systematic study that examines the association between hospital inpatient hospital value-based purchasing (HVBP) total performance, market competition, and OIE. This study fills the gap in the literature.

The Association of Hospital Magnet® Status and Pay-for-Performance Penalties.

The Centers for Medicare and Medicaid Services' Pay-for-Performance (P4P) programs aim to improve hospital care through financial incentives for care quality and patient outcomes. Magnet® recognition-a potential pathway for improving nurse work environments-is associated with better patient outcomes and P4P program scores, but whether these indicators of higher quality are substantial enough to avoid penalties and thereby impact hospital reimbursements is unknown. This cross-sectional study used a national sample of 2,860 hospitals to examine the relationship between hospital Magnet® status and P4P penalties under P4P programs: Hospital Readmission Reduction Program, Hospital-Acquired Conditions (HAC) Reduction Program, Hospital Value-Based Purchasing (VBP) Program. Magnet® hospitals were matched 1:1 with non-Magnet hospitals accounting for 13 organizational characteristics including hospital size and location. Post-match logistic regression models were used to compute a hospital's odds of penalties. In a national sample of hospitals, 77% of hospitals experienced P4P penalties. Magnet® hospitals were less likely to be penalized in the VBP program compared to their matched non-Magnet counterparts (40% vs. 48%). Magnet® status was associated with 30% lower odds of VBP penalties relative to non-Magnet hospitals. Lower P4P program penalties is one benefit associated with achieving Magnet® status or otherwise maintaining high-quality nurse work environments.

The Effects of Home Health Value-Based Purchasing on Home Health Care Quality in For-Profit and Nonprofit Agencies: A Comparative Interrupted Time-Series Analysis, 2012–2018

Beginning in 2016, the Home Health Value-Based Purchasing (HHVBP) model incentivized U.S. Medicare-certified home health agencies (HHAs) in nine states to improve quality of patient care and patient experience. Here, we quantified HHVBP effects upon quality over time (2012-2018) by HHA ownership (i.e., for-profit vs. nonprofit) using a comparative interrupted time-series design. Our outcome measures were Care Quality and Patient Experience indices composed of 10 quality of patient care measures and five patient experience measures, respectively. Overall, 17.7% of HHAs participated in the HHVBP model of which 81.4% were for-profit ownership. Each year after implementation, HHVBP was associated with a 1.59 (p < .001) percentage point increase in the Care Quality index among for-profit HHAs and a 0.71 (p = .024) percentage point increase in the Patient Experience index among nonprofits. The differences of quality improvement under the HHVBP model by ownership indicate variations in HHA leadership responses to HHVBP.

IMPROVING PATIENT SATISFACTION SCORES OF RESIDENT-RUN SERVICES IN INPATIENT SETTINGS

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Patient satisfaction has become one of the most important measures of performance in healthcare that affects value-based purchasing. Many factors affect patient satisfaction, including effective communication by the physician, materials provided by the hospital, quality of the room and food, quietness and cleanliness of the hospital, understanding of the disease process and health literacy, and interaction with nursing and ancillary staff. It is incumbent on residents to understand what contributes to patients’ satisfaction with their care - only then will they be able to have compassionate, therapeutic relationships with patients and engage them as partners, leading to better health outcomes and better compliance. METHODS: Pre-intervention data was collected with a survey that includes 13 questions related to physician’s introduction, communication and experience. The survey questionnaire used was unique and is different from the HCAHPS or Press Ganey survey. A total of 50 patients were recruited from services run by resident physicians, including Cardiology, General Medical Service, Hospitalist Service and Nephrology. The pre-intervention data was analyzed, and a plan formulated that included peer-driven education and a guest lecture that focused on introduction of the resident and providing business cards to patients; discussion of different types of patient-physician interactions, including a mutualistic patient-centered relationship; communication, barriers, and effective ways to communicate; provision of written material on how to address patient concerns, and the importance of treating patients with courtesy and respect. Business cards were produced for the residents who did not have them.After the intervention, the survey was repeated. The aim was to improve the patient satisfaction rate by 5%. RESULTS: Post-Intervention data showed improvement in in-patient satisfaction scores from a mean of 4.1 to 4.74. Post-intervention items that improved included patient recall of doctor’s names, doctors giving cards, doctors taking time to explain the medical condition, doctors listening carefully, doctors explaining new medications, and patient expectations being met (p-values 0.001-0.03). CONCLUSIONS: Patient satisfaction improved significantly after educating internal medicine residents on the importance of patient satisfaction, conducting lectures on communication skills, and providing relevant written material. CLINICAL IMPLICATIONS: Based on these results, residents should be educated routinely on the importance of patient satisfaction and should have workshops to improve their skills. DISCLOSURES: No relevant relationships by Anam Aqeel, source=Web Response no disclosure on file for Taimoor Haider; No relevant relationships by John Pamula, source=Web Response No relevant relationships by Oneeb Sanaullah, source=Web Response

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance.

The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Hospital value-based purchasing: How acute care advanced practice nurses demonstrate value.

Hospital value-based purchasing (HVBP) is a budget neutral initiative from the Centers for Medicare & Medicaid Services designed to adjust the hospital payment system based on health care quality data. Hospital value-based purchasing is designed to promote improved clinical outcomes and better patient experience in the acute care setting. Advanced practice registered nurses (APRNs) in the acute care setting are instrumental to the success of health care institutions under the current payer model in the United States health care system. When APRNs use their advanced knowledge and leadership skills to champion quality improvement and patient experience projects, they may increase financial reimbursement within the HVBP system, thus demonstrating value to the health care institution. Four basic steps could help APRNs demonstrate value to the organization, understand the standard, evaluate your performance compared with the standard, identify opportunities, and implement projects or participate in projects. This article provides a broad overview of the HVBP structure and describes how APRNs can positively influence performance measures, thereby potentially increasing hospital reimbursement.

Neighborhood Socioeconomic Disadvantage and Mortality Among Medicare Beneficiaries Hospitalized for Acute Myocardial Infarction, Heart Failure, and Pneumonia.

The Centers for Medicare and Medicaid Services' Hospital Value-Based Purchasing program uses 30-day mortality rates for acute myocardial infarction, heart failure, and pneumonia to evaluate US hospitals, but does not account for neighborhood socioeconomic disadvantage when comparing their performance. To determine if neighborhood socioeconomic disadvantage is associated with worse 30-day mortality rates after a hospitalization for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in the USA, as well as within the subset of counties with a high proportion of Black individuals. This retrospective, population-based study included all Medicare fee-for-service beneficiaries aged 65 years or older hospitalized for acute myocardial infarction, heart failure, or pneumonia between 2012 and 2015. Residence in most socioeconomically disadvantaged vs. less socioeconomically disadvantaged neighborhoods as measured by the area deprivation index (ADI). All-cause mortality within 30 days of admission. The study included 3,471,592 Medicare patients. Of these patients, 333,472 resided in most disadvantaged neighborhoods and 3,138,120 in less disadvantaged neighborhoods. Patients living in the most disadvantaged neighborhoods were younger (78.4 vs. 80.0 years) and more likely to be Black adults (24.6% vs. 7.5%) and dually enrolled in Medicaid (39.4% vs. 21.8%). After adjustment for demographics (age, sex, race/ethnicity), poverty, and clinical comorbidities, 30-day mortality was higher among beneficiaries residing in most disadvantaged neighborhoods for AMI (adjusted odds ratio 1.08, 95% CI 1.06-1.11) and pneumonia (aOR 1.05, 1.03-1.07), but not for HF (aOR 1.02, 1.00-1.04). These patterns were similar within the subset of US counties with a high proportion of Black adults (AMI, aOR 1.07, 1.03-1.11; HF 1.02, 0.99-1.05; pneumonia 1.03, 1.00-1.07). Neighborhood socioeconomic disadvantage is associated with higher 30-day mortality for some conditions targeted by value-based programs, even after accounting for individual-level demographics, clinical comorbidities, and poverty. These findings may have implications as policymakers weigh strategies to advance health equity under value-based programs.

How Total Performance Scores of Medicare Value-Based Purchasing Program Hospitals Change Over Time.

The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type. Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types. Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations. In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores. Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.

An Update: The Association between the CXO Role and Hospital Patient Experience Scores

Due to the healthcare industry’s shift from fee-for-service to value-based purchasing (VBP), many hospitals have changed their internal structure to adapt to the new environment by including a new C-suite leader, a Chief Experience Office (CXO). Payers have implemented various performance models to incentivize hospitals and other providers to incorporate the concept of patient-centeredness for improving the patient experience. The patient experience domain of the HCAHPS survey is an integral part of CMS’ hospital VBP program payment adjustment. Considering that most hospitals operate with under two percent profit margins, payment incentives or penalties can have a significant impact on their financial sustainability. So this study aimed to answer the question, does a hospital receive a return on a CXO investment in way of higher patient experience scores? Using Breen and colleagues (in-press) study data, we wanted to explore if our findings, post three years, would be consistent with their findings, that is, to determine if hospitals that continue to employ a formal full-time CXO role report higher HCAHPS scores than hospitals without this C-suite position. Our study’s findings were consistent with the Breen et al. study in that hospitals that have a formal CXO role are more likely to have higher HCAHPS scores as determined by the patient recommendation question as well as the hospital overall rating question included in the HCAHPS survey. We also provide additional insight into the organization characteristics of hospitals and the market factors associated with those hospitals that have filled the CXO role.

Smoke-Free Policies and 30-Day Mortality Rates for Chronic Obstructive Pulmonary Disease.

Smoke-free policies have been shown to impact 30-day readmission rates due to chronic obstructive pulmonary disease (COPD) among adults aged ≥65 years. However, little is known about the association between smokefree policies and 30-day mortality rates for COPD. Therefore, we investigated the association between comprehensive smoke-free policies and 30-day mortality rates for COPD. We used a cross-sectional study design and retrospectively examined risk-adjusted 30-day mortality rates for COPD across US hospitals in 1171 counties. Data were sourced from Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) Program, American Hospital Association (AHA) Annual Surveys, US Census Bureau Current Population Survey, and US Tobacco Control Laws Database from the American Nonsmokers' Rights Foundation (ANRF). Data were averaged at the county level for years 2015-2018. Hierarchical Poisson models adjusted for differences in hospital characteristics and accounted for the clustering of hospitals within a county were used. Our findings show a consistent association between stronger smoke-free policies and a reduction in COPD mortality. When evaluating smoke-free policy, county characteristics, and hospital characteristics individually, we found that counties with full coverage or partial coverage had a reduced incidence rate of COPD mortality compared to no coverage counties. After adjusting for the county and hospital characteristics, counties with full coverage of smoke-free policies had a reduced rate of 30-day COPD mortality (adjusted incidence rate ratio [IRR]: 0.87, 95% CI: 0.79, 0.96) compared to counties with no policy coverage. Comprehensive smoke-free policies are associated with a reduction in 30-day mortality following hospital admission for COPD. Partial smoke-free legislation is an insufficient preventative measure. These findings have strong implications for hospital policy-makers, suggesting that policy interventions to reduce COPD-related 30-day mortality should include implementing smoke-free policies and public health policy-makers to incentivize comprehensive smokefree policies.

Future Directions in Research to Improve Care Transitions From Hospital Discharge.

Future Directions in Research to Improve Care Transitions From Hospital Discharge.

Recommendation for a Pilot MCDA Tool to Support the Value-Based Purchasing of Generic Medicines in the UAE.

Introduction: In recent periods the United Arab Emirates (UAE) has strengthened economic measures in its pharmaceutical policy by promoting local manufacturing and facilitating the use of generic medicines. International examples indicate the importance of quality control elements in the implementation of cost containment policies. Multicriteria Decision Analysis (MCDA) is increasingly used in health care to facilitate health care decision based on multiple objectives. Our objective was to develop a pilot MCDA tool for repeated use to support the value-based purchasing of generic medicines in the UAE. Methods: An international evidence framework was adapted to UAE in a multistakeholder workshop organized by Dubai Health Authority. After validating the relevance of nine criteria in the local jurisdiction, participants decided the ranking and weight of each criterion by anonymous voting. Results: The top four criteria focused on quality elements starting with real-world clinical or economic outcomes (with 19.8% weight), followed by the quality assurance of manufacturing (17.3%), then evidence on the equivalence with the original product (14.8%), and drug formulation and stability (12.3%). The pharmaceutical acquisition cost criteria ranked fifth with 9.4% weight. The bottom four criteria, including reliability of drug supply, macroeconomic benefit, pharmacovigilance and added value services related to the product had similar weights in the range of 5.5–7.7%. Conclusion: Policy-makers in Dubai put high emphasis of value-based health care by incentivizing manufacturers of off-patent pharmaceuticals to generate additional scientific evidence compared to the mandatory minimum and acknowledging efforts to improve quality standards. The MCDA tool is considered suitable to improve the transparency and consistency of decision making in UAE for off-patent pharmaceuticals, and subsequently for other health technologies.

Advance Care Planning Protocols and Hospitalization Rates in Home Health Value-Based Purchasing

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Medicare's Hospital Value-Based Purchasing Program Values Quality over QALYs.

Medicare's Hospital Value-Based Purchasing Program (HVBP) is the first national pay-for-performance program to combine measures of quality of care with a measure of episode spending. We estimated the implicit tradeoffs between mortality reduction and spending reduction. To earn points in HVBP, a hospital can either lower mortality or reduce spending, creating a tradeoff between the 2 measures. We analyzed the quality performance and earned points of 2814 hospitals using publicly available data. We then quantified the tradeoffs between spending and mortality in terms of quality-adjusted life-years (QALYs). If incentives in the program were balanced, then the tradeoff between spending and QALYs should be comparable with those of high-value health interventions, roughly $50,000 to $200,000 per QALY. Instead, the tradeoff in HVBP was about $1.2 million per QALY. HVBP overvalues improvements in quality of care relative to spending reductions. We propose 2 possible policy adjustments that could improve incentives for hospitals to deliver high-value care.

Development of Episode-Based Cost Measures for the US Medicare Merit-based Incentive Payment System.

The Merit-based Incentive Payment System (MIPS), established as part of the Quality Payment Program, is a Medicare value-based payment program that evaluates clinicians' performance across 4 categories: quality, cost, promoting interoperability, and improvement activities. The cost category includes novel episode-based measures designed for targeted evaluation of the resource use of specific conditions. This report describes the development of episode-based cost measures and their role in the shift from volume-based to value-based purchasing. Episode-based cost measures focus on resource use related to the treatment of a specific condition or procedure. The measures exclude health care costs unrelated to the condition or procedure of focus. The episode-based cost measures provide a nuanced examination of resource use that can be used alongside quality metrics to identify opportunities to improve the value by capturing costs that are clinically related to the care being delivered within a given patient-clinician relationship of care delivered to patients. These measures were developed with the input of clinical committees composed of over 320 clinicians from 127 specialty societies and stakeholder organizations. The MIPS program currently evaluates clinician cost category performance based on 2 population-based cost measures (Medicare spending per beneficiary and total per capita costs) in addition to 18 episode-based cost measures. Additional episode-based cost measures are currently under development. The transition to value-based payment requires an accurate assessment of clinician effect on health care quality and cost. The use of episode-based cost measures to assess clinician influence on health care costs for high-priority conditions and procedures is an important step. The Centers for Medicare & Medicaid Services is introducing MIPS Value Pathways that will align episode-based cost measures with related quality measures to further incentivize the transition from fee-for-service to value-based care.

Association between Payer-Class and Patient Satisfaction Scores in an Academic Urology Outpatient Clinic.

As physician reimbursement models transition from fee-for-service to value-based purchasing, patient satisfaction is becoming an important payment modifier. Studies have shown correlation between nonmodifiable patient attributes and satisfaction scores. This study aims to investigate potential patient bias in survey scores associated with payer type in an academic urology outpatient clinic setting. The survey results of 20,944 patients seen in an academic urology clinic were analyzed, and the weighted mean±SD scores of patient experience in 6 major payer categories were compared: 1) commercial insurance, 2) Medicare, 3) Medicaid, 4) other government plans, 5) workers' comp and 6) self-pay/uncompensated. ANOVA and Tukey-Kramer Honestly Significant Difference were utilized to assess statistical significance. Medicare patients reported the highest satisfaction scores (93.03), followed by other government coverage (91.49), commercial insurance (91.32), workers' comp (90.72), Medicaid (89.21) and self-pay/uncompensated (89.00). ANOVA analysis resulted in an F value of 40.198 (p <0.001). Tukey-Kramer demonstrated statistical significance in the difference between the means of the following groups: commercial vs Medicaid (p <0.001), commercial vs Medicare (p <0.001), commercial vs self-pay/uncompensated (p <0.01), other government vs Medicaid (p <0.001), other government vs Medicare (p <0.01), Medicaid vs Medicare (p <0.001), Medicare vs self-pay/uncompensated (p <0.001). Our data suggest that patient experience scores are impacted by the type of coverage the patient carries and not only by the quality of care provided. Urology clinicians should be aware of these nuances when selecting MIPS quality reporting metrics. Currently, these biased scores may have an impact on physicians' reimbursement, and policymakers should consider adjusting reimbursement according to payer-mix.

The Role of Patient Satisfaction in Hospitals’ Medicare Reimbursements

Medicare uses a pay-for-performance program to reimburse hospitals. One of the key input measures in the performance formula is patient satisfaction with their hospital care. Physicians and hospitals, however, have raised concerns regarding questions related to patient satisfaction with pain management during hospitalization. They report feeling pressured to prescribe opioids to alleviate pain and boost satisfaction survey scores for higher reimbursements. This overprescription of opioids has been cited as a cause of current opioid crisis in the United States. Due to these concerns, Medicare stopped using pain management questions as inputs in its payment formula. The authors collected multiyear data from six diverse data sources, employed propensity score matching to obtain comparable groups, and estimated difference-in-difference models to show that, in fact, pain management was the only measure to improve in response to the pay-for-performance system. No other input measure showed significant improvement. Thus, removing pain management from the formula may weaken the effectiveness of the Hospital Value-Based Purchasing Program at improving patient satisfaction, which is one of the key goals of the program. The authors suggest two divergent paths for Medicare to make the program more effective.

Bundled Payment Models in Spine Surgery.

Study Design:The following is a narrative discussion of bundled payments in spine surgery.Objective:The cost of healthcare in the United States has continued to increase. To lower the cost of healthcare, reimbursement models are being investigated as potential cost saving interventions by driving incentives and quality improvement in fields such a spine surgery.Methods:Narrative overview of literature pertaining to bundled payments in spine surgery synthesizing findings from computerized databases and authoritative texts.Results:Spine surgery is challenging to define payment modes because of high cost variability and surgical decision-making nuances. While implementing bundled care payments in spine surgery, it is important to understand concepts such as value-based purchasing, episodes of care, prospective versus retrospective payment models, one versus two-sided risk, risk adjustment, and outlier protection. Strategies for implementation underscore the importance of risk stratification and modeling, adoption of evidence based clinical pathways, and data collection and dissemination. While bundled care models have been successfully implemented, challenges facing institutions adopting bundled care payment models include financial stressors during adoption of the model, distribution of risks, incentivization of treating only low risk patients, and nuanced variation in procedures leading to variation in costs.Conclusion:An alternative for fee for service payments, bundled care payments may lead to higher cost savings and surgeon accountability in a patient’s care.

The interaction between high-level electronic medical record adoption and hospitalist staffing levels: A focus on value-based purchasing.

This study sought to understand the relationship of hospital performance with high-level electronic medical record (EMR) adoption, hospitalists staffing levels, and their potential interaction. We evaluated 2,699 non-federal, general acute hospitals using 2016 data merged from four data sources. We performed ordinal logistic regression of hospitals' total performance score (TPS) on their EMR capability and hospitalists staffing level while controlling for other market- and individual-level characteristics. Hospitalists staffing level is shown to be positively correlated with TPS. High-level EMR adoption is associated with both short-term and long-term improvement on TPS. Large, urban, non-federal government hospitals, and academic medical centers tend to have lower TPS compared to their respective counterparts. Hospitals belonging to medium- or large-sized healthcare systems have lower TPS. Higher registered nurse (RN) staffing level is associated with higher TPS, while higher percentage of Medicare or Medicaid share of inpatient days is associated with lower TPS. Although the main effects of hospitalists staffing level and EMR capability are significant, their interaction is not, suggesting that hospitalists and EMR act through separate mechanisms to help hospitals achieve better performance. When hospitals are not able to invest on both simultaneously, given financial constraints, they can still reap the full benefits from each. Hospitalists staffing level and EMR capability are both positively correlated with hospitals' TPS, and they act independently to bolster hospital performance.

Race to the Top of the Hospital Value-Based Purchasing Program.

Medicare's Hospital Valued-Based Purchasing (HVBP) program measures hospitals' total performance score (TPS); its measurement strategies have changed regularly since its rollout in 2013. Because the program influences care delivery, it is important to examine how the policy has changed hospitals' behavior and how it may inform future policies. The purpose of this study was to assess the relationship between hospitals' performance on TPS annually from 2013 to 2018 and organizational characteristics. Using the HVBP TPS from 2013 to 2018 and associated hospital characteristics-hospital size, teaching hospital status, system membership, ownership type, urban/rural location, average percentages of patients from Medicare and Medicaid, operating margins, percentages of inpatient revenue as a proportion of total revenue, and case mix index-we conducted a retrospective cohort study of all U.S. hospitals participating in the HVBP program. Regression and panel analyses found that organizations that were expected to have robust and rigid resources were unable to score in the superior category consistently. In addition, organizations were unable to consistently perform positively over time because of changes in the HVBP program measurement and the required organizational responses. Policymakers should consider the ability of organizations to respond to changes to the HVBP program. Likewise, healthcare managers, particularly those in larger organizations, should seek to remove bureaucracy or allow for greater resource slack to meet these changes.