Value-Based Purchasing Program Has Little Effect

Bridget M. Kuehn

June 16, 2017

A Medicare hospital quality improvement program has failed to yield reduced mortality for patients with acute myocardial infarction or heart failure 4 years into the program, a new study has found. The study was published online June 14 in the New England Journal of Medicine. But participating hospitals did see a reduction in pneumonia-related deaths compared with control hospitals.

To improve the value of care received by Medicare patients and reduce wasteful spending, the Patient Protection and Affordable Care Act created the Hospital Value-Based Purchasing program, which was launched in 2013. It initially provided incentives of up to 1% increases in a hospital's Medicare reimbursements for meeting certain targets for clinical processes, patient satisfaction, and patient outcomes; incentives were later increased to 2%.

So far, some assessments of the program's effectiveness have yielded disappointing results. Previous studies found no improvement in clinical processes or patient experience in the first 9 months ( Heath Serv Res. 2015;50:81-97) and no mortality benefit during the first 30 months ( BMJ. 2016;353:i2214).

"Despite the well-intended goals of value-based purchasing programs, evidence that these programs have improved quality and spending outcomes is mixed and far from convincing," Andrew Ryan, PhD, associate professor of health management and policy at the University of Michigan, Ann Arbor, and colleagues write.

To determine whether the program may have stronger effects over the long term, the researchers compared outcomes at participating hospitals with control hospitals 4 years after implementation. Control hospitals were all Medicare-designated Critical Access Hospitals and were exempt from the program's requirements.

Using composite measures, the analysis found there was not a significant difference in clinical process (0.079 standard deviation [SD]; 95% confidence interval [CI], −0.140 to 0.299) or patient experience (−0.092 SD; 95% CI, −0.307 to 0.122). There was also not a significant reduction in deaths among patients admitted for acute myocardial infarction (−0.282 percentage points; 95% CI, −1.715 to 1.152) or heart failure (−0.212 percentage points; 95% CI, −0.532 to 0.108).

The study did find a significant reduction in pneumonia-related deaths (−0.431 percentage points; 95% CI, −0.714 to −0.148) in participating hospitals compared with controls. But the authors doubt this finding, noting the difference was driven by increases in pneumonia deaths at control hospitals.

"Because the incentives in the program did not appear to improve performance with regard to the clinical-process indicators related to pneumonia, it is unlikely that [the value-based purchasing program] would have reduced mortality among the patients who were admitted for pneumonia, since such reductions are harder to achieve than improvements in clinical process," the authors wrote.

Ron Greeno, MD, president of the Society for Hospital Medicine, told Medscape Medical News that he is not surprised that the program did not result in better outcomes. He explained it is difficult to identify accurate markers of care quality that, if improved, will boost patient outcomes. It can also be hard to attribute improvements in outcomes to the appropriate providers. He suggested it might take multiple iterations to come up with appropriate measures and incentives to boost the quality of care and cut costs in the health system.

"It's a difficult thing to do," Dr Greeno said. "But that doesn't mean it is not the right thing to do."

Dr Greeno, who is also a senior advisor for medical affairs at TeamHealth, suggested that value-based initiatives should get more physician input on quality markers.

"The more you get physicians involved in selecting these measures, the more likely they will be to lead to better [patient] outcomes," he said.

The authors note that that the program's complex design and focus on payment incentives vs penalties may explain why it has not been as successful as Medicare's Hospital Readmissions Reduction Program, which uses substantial reductions in reimbursements to penalize hospitals that do not improve admission rates.

"It is possible that alternative incentive designs — including those with simpler criteria for performance and larger financial incentives — might have led to greater improvement among hospitals," the authors conclude.

Dr Greeno agreed that incentives must be large enough to be meaningful, and they must reach the individual physician level.

Ultimately, he said, it is essential to continue to improve programs to promote value-based care.

"Paying providers just for production is not going to get us where we need to go," Dr Greeno said. "We need to reward physicians for better outcomes and lower costs. It's the only way we are going to save the health system."

All study authors report receiving grants from the National Institutes of Health. One author received personal fees from ArborMetrix, Emory University, Stanford University, the University of Pittsburg, the Carolinas Medical Center, and the Texas Health Institute. One author is employed by 1199 SEIU United Healthcare Workers East in New York City. Kristin Maurer received personal fees from Mathematica Policy Research Institute. Dr Greeno has disclosed no relevant financial relationships.

N Engl J Med. 2017;376:2358-2366. Abstract

For more news, join us on Facebook and Twitter


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.