PQRS Participation, Inappropriate Utilization of Health Care Services, and Medicare Expenditures

Changes in patient experiences and assessment of gaming among large clinician practices in precursors of the Merit-Based Incentive Payment System

Question

Do clinician practices game pay-for-performance programs by selectively reporting measures on which they already perform well, and does mandating public reporting on patient experience measures improve care?

Findings

In this cross-sectional analysis of patient experience data from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, practices were more likely to voluntarily include CAHPS measures in a Medicare pay-for-performance program when they previously scored higher on these measures. However, mandatory public reporting of CAHPS measures was not associated with improved patient experiences with care.

Meaning

These findings support calls to end voluntary measure selection in public reporting and pay-for-performance programs, including Medicare’s Merit-Based Incentive Payment System, but also suggest that requiring practices to report on patient experiences may not produce gains.

Importance

Medicare’s Merit-Based Incentive Payment System (MIPS), a public reporting and pay-for-performance program, adjusts clinician payments based on publicly reported measures that are chosen primarily by clinicians or their practices. However, measure selection raises concerns that practices could earn bonuses or avoid penalties by selecting measures on which they already perform well, rather than by improving care—a form of gaming. This has prompted calls for mandatory reporting on a smaller set of measures including patient experiences.

Objective

To examine (1) practices’ selection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures for quality scoring under the pay-for-performance program and (2) the association between mandated public reporting on CAHPS measures and performance on those measures within precursor programs of the MIPS.

Design, Setting, and Participants

This cross-sectional study included 2 analyses. The first analysis examined the association between the baseline CAHPS scores of large practices (≥100 clinicians) and practices’ selection of these measures for quality scoring under a pay-for-performance program up to 2 years later. The second analysis examined changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. A difference-in-differences analysis of 2012 to 2017 fee-for-service Medicare CAHPS data was conducted to compare changes in patient experiences between large practices (111-150 clinicians) that became subject to this reporting mandate and smaller unaffected practices (50-89 clinicians). Analyses were conducted between October 1, 2020, and July 30, 2021.

Main Outcomes and Measures

The primary outcomes of the 2 analyses were (1) the association of baseline CAHPS scores of large practices with those practices’ selection of those measures for quality scoring under a pay-for-performance program; and (2) changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014.

Results

Among 301 large practices that publicly reported patient experience measures, the mean (IQR) age of patients at baseline was 71.6 (70.4-73.2 ) years, and 55.8% of patients were women (IQR, 54.3%-57.7%). Large practices in the top vs bottom quintile of patient experience scores at baseline were more likely to voluntarily include these scores in the pay-for-performance program 2 years later (96.3% vs 67.9%), a difference of 28.4 percentage points (95% CI, 9.4-47.5 percentage points; P = .004). After 2 to 3 years of the reporting mandate, patient experiences did not differentially improve in affected vs unaffected practices (difference-in-differences estimate: −0.03 practice-level standard deviations of the composite score; 95% CI, −0.64 to 0.58; P = .92).

Conclusions and Relevance

In this cross-sectional study of US physician practices that participated in precursors of the MIPS, large practices were found to select measures on which they were already performing well for a pay-for-performance program, consistent with gaming. However, mandating public reporting was not associated with improved patient experiences. These findings support recommendations to end optional measures in the MIPS but also suggest that public reporting on mandated measures may not improve care.

A Predictive Model of Reintubation after Cardiac Surgery Using the Electronic Health Record

BACKGROUND

Reintubation and prolonged intubation after cardiac surgery are associated with significant complications. Despite these competing risks, providers frequently extubate patients with limited insight into the risk of reintubation at the time of extubation. Achieving timely, successful extubation remains a significant clinical challenge.

METHODS

Based on an analysis of 2835 patients undergoing cardiac surgery at our institution between November 2017 and July 2020, we developed a model for an individual's risk of reintubation at the time of extubation. Predictors were screened for inclusion in the model based on clinical plausibility and availability at the time of extubation. Rigorous data reduction methods were used to create a model that could be easily integrated into clinical workflow at the time of extubation.

RESULTS

In total, 90 patients (3.2%) were reintubated within 48 hours of initial extubation. Number of inotropes [1 (adjusted odds ratio (OR), 15.4; 95% confidence interval (CI) 6.5-47.6; p <.001), ≥2 (OR, 62.7; 95% CI 14.3-279.5; p<.001)]; dexmedetomidine dose (OR, 3.0 [per mcg/kg/h]; 95% CI 1.9-4.7; p <.001), time to extubation (OR, 1.04 [per six hour increase]; 95% CI 1.02-1.05; p <.001), and respiratory rate (OR, 1.04 [per breath/min.]; 95% CI 1.01-1.07; p <.001) were the best predictors for the model, which displayed excellent discriminative capacity (the area under the receiver operating characteristic, 0.86; 95% CI 0.84-0.89).

CONCLUSIONS

An improved understanding of reintubation risk may lead to improved decision-making at extubation and targeted interventions to decrease reintubation in high-risk patients. Future studies are needed to optimize timing of extubation.

Rationale and design of extended cancer education for longer term survivors (EXCELS): a randomized control trial of 'high touch' vs. 'high tech' cancer survivorship self-management tools in primary care

Background

Breast, colorectal, and prostate cancer survivors are at increased risk for late and long-term effects post-treatment. The post-treatment phase of care is often poorly coordinated and survivors navigate follow-up care with minimal information or guidance from their healthcare team. This manuscript describes the Extended Cancer Education for Longer-term Survivors (EXCELS) in Primary Care protocol. EXCELS is a randomized controlled trial to test the efficacy of patient-level self-management educational strategies on adherence to preventative health service use and cancer survivorship follow-up guidelines.

Methods

The EXCELS trial compares four conditions: (1) EXCELS-website (e.g., a mobile-optimized technology platform); (2) EXCELS-health coaching; (3) EXCELS-website and health coaching; and (4) a print booklet. Approximately 480 breast, colorectal, and prostate survivors will be recruited through the New Jersey Primary Care Research Network (NJPCRN) and New Jersey State Cancer Registry (NJSCR). Eligible survivors (diagnosed stages 1–3) must have completed active treatment, access to a phone and a computer, smartphone or tablet with internet access, and be able to speak and read English. Patient assessments occur at baseline, 6, 12, and 18 months. The primary outcomes are increased engagement in preventive health services and monitoring for cancer recurrence and treatment-related late effects.

Discussion

The EXCELS trial is the first to test cancer survivorship educational self-management interventions for cancer survivors in a primary care context. Findings from this trial will inform successful implementation and engagement strategies for longer-term, post-treatment cancer survivors managed in primary care settings.

Trial registration

Registered August 1, 2017 at ClinicalTrials.gov, trial # NCT03233555.

Do Health Information Exchanges Deter Repetition of Medical Services?

Repetition of medical services by providers is one of the major sources of healthcare costs. The lack of access to previous medical information on a patient at the point of care often leads a physician to perform medical procedures that have already been done. Multiple healthcare initiatives and legislation at both the federal and state levels have mandated Health Information Exchange (HIE) systems to address this problem. This study aims to assess the extent to which HIE could reduce these repetitions, using data from Centers for Medicare 8 Medicaid Services and a regional HIE organization. A 2-Stage Least Square model is developed to predict the impact of HIE on repetitions of two classes of procedures: diagnostic and therapeutic. The first stage is a predictive analytic model that estimates the duration of tenure of each HIE member-practice. Based on these estimates, the second stage predicts the effect of providers’ HIE tenure on their repetition of medical services. The model incorporates moderating effects of a federal quality assurance program and the complexity of medical procedures with a set of control variables. Our analyses show that a practice's tenure with HIE significantly lowers the repetition of therapeutic medical procedures, while diagnostic procedures are not impacted. The medical reasons for the effects observed in each class of procedures are discussed. The results will inform healthcare policymakers and provide insights on the business models of HIE platforms.

Interventions to reduce corruption in the health sector

BACKGROUND

Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.

OBJECTIVES

Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.

SEARCH METHODS

We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.

SELECTION CRITERIA

For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.

DATA COLLECTION AND ANALYSIS

One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.

MAIN RESULTS

No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis.One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence).One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty.One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence).One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence).A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.

AUTHORS' CONCLUSIONS

There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.