Paying Hospitals Didn’t Improve Mortality Rates – Nurse Recruiter

Paying Hospitals Didn’t Improve Mortality Rates

James Steidl –

A study by the New England Journal of Medicine has cast doubt on a central premise of the Affordable Care Act (ACA). The ACA took inspiration from Medicare’s efforts to pay hospitals based on how they perform, which was thought to save money while improving health care. However, the study has found that the mortality rate at hospitals that participated in the performance-based payment program was about the same as the mortality rate at non-participating hospitals.

In an article in the Miami Herald, the vice president of the company overseeing the pay for performance programs, Blair Childs, said that lowering mortality wasn’t the primary goal of the demonstration project. Some of the other elements that were examined included whether the hospital staff performed certain procedures that were deemed helpful or necessary, such as giving heart attack patients a beta-blocker upon arrival and then again at discharge. By those standards, the participants in the program surpassed other hospitals, said Mr. Childs.

“The goal of HQID was to determine whether incentives would improve care processes in hospitals and it did do that, there’s no question,” Childs said.

Childs agreed with the New England Journal article that focusing on these “process” measures might not be the best way to actually improve patient outcomes. He said a current project Premier is running called Quest among 293 hospitals has found that a better way to reduce mortality is to focus on preventing septic shock, when the bloodstream is infected with bacteria, and respiratory conditions such as pneumonia in patients on ventilators.

In a statement, The Centers for Medicare & Medicaid Services said: “The Premier demonstration was an effort under the last administration, separate from the value-based purchasing model that we’re implementing into Medicare’s hospital payment system. Our model for improving quality in hospitals is much more aggressive, covering all hospitals and including both incentives for hospitals that do well on quality metrics, and consequences for hospitals that do not improve.”

CMS has said it eventually wants to tie hospital payment to actual outcomes. But in the value-based program’s first year, process measures will account for 70 percent of hospitals’ financial incentives, with patient satisfaction scores making up the rest. In the second year, starting in fall 2013, Medicare will take into account mortality rates for three conditions — heart failure, heart attack and pneumonia. But process measures will continue to play a dominant part in judging hospital performance.

In an interview, Jha cautioned Medicare against making hospitals accountable for too many different things, diffusing their focus from the ones that matter most. For instance, he said, one measure Medicare is using — what percent of patients received written instructions about how to take care of themselves after discharge — has been shown in studies to have no effect on whether patients are readmitted.

“At the end of the day, you are going to ask people to make improvements and you want them to focus on what’s important,” Jha said. “And if you give them 18 different metrics and some are easy but not that important, and some are hard but important, people are going to naturally gravitate toward what’s easy and you’re not going to have meaningful impact.”

Chas Roades, chief research officer at The Advisory Board Company, a consulting firm, said he believes Medicare’s new effort will improve quality in the long-term. But he cautioned that it might take a while.

“Like most of these kinds of quality improvements, I think the early gains are going to be the very low performers, and less about the top performers improving even more,” he said. “What I think it will do in the reasonably near term is reduce the spread between the worst performers and the best performers, mostly by pulling up the bottom.”

Dr. Donald Berwick, the former CMS administrator, said he hadn’t read the study and thus couldn’t comment on it. But he said that “conceptually,” paying for performance “has to be the right way to go” because the current system of reimbursement for procedures has proven not to work. Getting the right measurements will be crucial, he said. “The angel may be in the details,” he said.

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