The value of value-based purchasing

In the first four years of the Hospital Quality Incentive Demonstration (HQID) project operated by the Centers for Medicare & Medicaid Improvement (CMS) and Premier, Inc., HQID hospitals improved their composite quality scores by 17.2 percent across five clinical areas. If every hospital were able to replicate this level of performance, an estimated $4.5 billion and 70,000 lives would be saved each year, according to CMS and Premier.

Effects of pay for performance on the quality of primary care in England

BACKGROUND

A pay-for-performance scheme based on meeting targets for the quality of clinical care was introduced to family practice in England in 2004.

METHODS

We conducted an interrupted time-series analysis of the quality of care in 42 representative family practices, with data collected at two time points before implementation of the scheme (1998 and 2003) and at two time points after implementation (2005 and 2007). At each time point, data on the care of patients with asthma, diabetes, or coronary heart disease were extracted from medical records; data on patients' perceptions of access to care, continuity of care, and interpersonal aspects of care were collected from questionnaires. The analysis included aspects of care that were and those that were not associated with incentives.

RESULTS

Between 2003 and 2005, the rate of improvement in the quality of care increased for asthma and diabetes (P<0.001) but not for heart disease. By 2007, the rate of improvement had slowed for all three conditions (P<0.001), and the quality of those aspects of care that were not associated with an incentive had declined for patients with asthma or heart disease. As compared with the period before the pay-for-performance scheme was introduced, the improvement rate after 2005 was unchanged for asthma or diabetes and was reduced for heart disease (P=0.02). No significant changes were seen in patients' reports on access to care or on interpersonal aspects of care. The level of the continuity of care, which had been constant, showed a reduction immediately after the introduction of the pay-for-performance scheme (P<0.001) and then continued at that reduced level.

CONCLUSIONS

Against a background of increases in the quality of care before the pay-for-performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme.

The Australian Childhood Immunisation Register-A model for universal immunisation registers?

The Australian Childhood Immunisation Register (ACIR) was established in 1996 as an opt-out register built on the platform of Medicare, the universal national health insurance scheme. Introduction of financial incentives for providers and parents, linked to the ACIR, followed from 1998. Over the subsequent decade, national levels for receipt of all vaccines by 12, 24 and 72 months of age have risen to 91%, 93%, and 88%, respectively. Conscientious objection to immunisation can be registered, with retention of eligibility for incentives. The ACIR has been important in implementation of a range of measures to improve childhood immunisation coverage in Australia. Linkage of a universal childhood immunisation register to national health insurance schemes has potential applicability in a variety of settings internationally.

The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK

BACKGROUND

Accurate spirometry is important in the management of COPD. The UK Quality and Outcomes Framework pay-for-performance scheme for general practitioners includes spirometry related indicators within its COPD domain. It is not known whether high achievement against QOF spirometry indicators is associated with spirometry to BTS standards.

METHODS

Data were obtained from the records of 3,217 patients randomly sampled from 5,649 patients with COPD in 38 general practices in Rotherham, UK. Severity of airflow obstruction was categorised by FEV1 (% predicted) according to NICE guidelines. This was compared with clinician recorded COPD severity. The proportion of patients whose spirometry met BTS standards was calculated in each practice using a random sub-sample of 761 patients. The Spearman rank correlation between practice level QOF spirometry achievement and performance against BTS spirometry standards was calculated.

RESULTS

Spirometry as assessed by clinical records was to BTS standards in 31% of cases (range at practice level 0% to 74%). The categorisation of airflow obstruction according to the most recent spirometry results did not agree well with the clinical categorisation of COPD recorded in the notes (Cohen's kappa = 0.34, 0.30 - 0.38). 12% of patients on COPD registers had FEV1 (% predicted) results recorded that did not support the diagnosis of COPD. There was no association between quality, as measured by adherence to BTS spirometry standards, and either QOF COPD9 achievement (Spearman's rho = -0.11), or QOF COPD10 achievement (rho = 0.01).

CONCLUSION

The UK Quality and Outcomes Framework currently assesses the quantity, but not the quality of spirometry.

RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment

OBJECTIVES

The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient.

METHODS

The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student's t-test and repeated-measures analysis of variance, as appropriate.

RESULTS

The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was 282.82 USD, which increased to 301.94 USD in the second phase (p = 0.0004).

CONCLUSIONS

The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).

Activity-based funding for National Health Service hospitals in England: managers' experience and expectations

Activity-based funding of hospital services has been introduced progressively since 2003 in the National Health Service (NHS) in England, under the name 'Payment by Results' (PbR). It represents a major change from previous funding arrangements based on annual "block" payments for large bundles of services. We interviewed senior local NHS managers about their experience and expectations of the impact of PbR. A high degree of 'NHS solidarity' was apparent, and competition between NHS hospitals was muted. PbR has been introduced against a background of numerous other efficiency incentives, and managers did not detect a further PbR-specific boost to efficiency. No impact on care quality, either positive or negative, is yet evident.