To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes is a very big leap.
by Richard Bankowitz, MD, MBA
In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.
The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.
Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.
Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.
Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative. QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.
To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.
Richard Bankowitz, MD, MBA, FACP,
chief medical officer,
Premier Inc. healthcare alliance
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.