Little Evidence Pay-For-Performance Improves Outcomes

By Christine Kern, contributing writer

Findings undercut current trends in payment models.

There was little evidence to suggest the Hospital Value-Based Purchasing (HVBP) program had any real impact on 30 day mortality for three incentivized conditions — including acute myocardial infarction, heart failure, and pneumonia — according to the findings of a five-year observational study published by The BMJ. The research was designed to determine whether or not the pay-for-performance payment model introduced by Medicare actually incentivized higher quality care, resulting in better patient outcomes. The study also measured whether or not the pay for performance program benefitted poor performing hospitals.

The study, led by researchers from Harvard School of Public Health, Brigham and Women’s Hospital, and the VA Boston Healthcare System, compared 30-day mortality for acute myocardial infarction, heart failure, and pneumonia at both incentivized hospitals and ones that were ineligible for the HVBP program. They found death rates for those conditions at HVBP-participating hospitals dropped 0.13 percent for each quarter during the study period versus 0.14 percent at non-incentivized hospitals.

Researchers examined 2008-2013 data from 2.4 million patients at 4,267 acute care hospitals in the U.S. Of those hospitals, 2,919 were in the HVBP program and 1,348 served as controls.

By comparison, patients in HVBP hospitals were slightly younger, more likely to be male, black, and have Medicaid coverage than those in nonparticipating hospitals, and also were also more likely to have high blood pressure, diabetes, and chronic kidney disease and less likely to have congestive heart failure.

At the end of the study, researchers concluded the difference in death rates between the two groups was “small and nonsignificant,” and even among subgroups of hospitals and poor performers, they found no association between HVBP and improved outcomes. The study has important implications not just for American healthcare, but also for international efforts using financial incentives to drive improvements in the quality of care in hospitals.

While the study presented no explanation for the failure of HVBP to improve outcomes, it does have potential serious implications for the future of healthcare payment models. The researchers did suggest the study was too narrow, focusing on just a few measured processes and patient experience scores, rather than underlying processes that might have more of an impact. Another likely explanation is that public reporting of performance conditions, which began in 2008, already had prompted most of the gains in patient outcomes.

According to the CMS, the HVBP program attaches value-based purchasing to the payment system that accounts for the largest share of Medicare spending, affecting payment for inpatient stays in over 3,500 hospitals across the country. Under the program, participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of the services they provide. Congress authorized Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure developed for the Hospital Inpatient Quality Reporting (IQR) Program, which was authorized by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Ultimately, the study authors concluded, “Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes.”