Association between value-based purchasing score and hospital characteristics

The Impact of Value-Based Payment Models for Networks of Care and Transmural Care: A Systematic Literature Review

INTRODUCTION

Value-based healthcare has potential for cost control and quality improvement. To assess this, we review the evidence on the impact of value-based payment (VBP) models in the context of networks of care (NOC) and transmural care.

METHODS

We used the PRISMA guidelines for this systematic literature review. We searched eight databases in July 2021. Subsequently, we conducted title and abstract and full-text screenings, and extracted information in an extraction matrix. Based on this, we assessed the evidence on the effects of VBP models on clinical outcomes, patient-reported outcomes/experiences, organization-related outcomes/experiences, and costs. Additionally, we reviewed the facilitating and inhibiting factors per VBP model.

FINDINGS

Among articles studying shared savings and pay-for-performance models, most outline positive effects on both clinical and cost outcomes, such as preventable hospitalizations and total expenditures, respectively. Most studies show no change in patient satisfaction and access to care when adopting VBP models. Providers' opinions towards the models are frequently negative. Transparency and communication among involved stakeholders are found to be key facilitating factors, transversal to all models. Additionally, a lack of trust is an inhibitor found in all VBP models, together with inadequate targets and insufficient incentives. In bundled payment and pay-for-performance models, complexity in the structure of the program and lack of experience in implementing required mechanisms are key inhibitors.

CONCLUSIONS

The overall positive effect on clinical and cost outcomes validates the success of VBP models. The mostly negative effects on organization-reported outcomes/experiences are corroborated by findings regarding providers' lack of awareness, trust, and engagement with the model. This may be justified by their exclusion from the design of the models, decreasing their sense of ownership and, therefore, motivation. Incentives, targets, benchmarks, and quality measures, if adequately designed, seem to be important facilitators, and if lacking or inadequate, they are key inhibitors. These are prominent facilitators and inhibitors for P4P and shared savings models but not as prominent for bundled payments. The complexity of the scheme and lack of experience are prominent inhibitors in all VBP models, since all require changes in several areas, such as behavioral, process, and infrastructure.

Is the Hospital Value-Based Purchasing Program Associated with Reduced Hospital Readmissions?

Introduction

Hospital readmissions have been associated with adverse outcomes and elevated financial costs to patients, families, and hospitals across the United States. Historically, nearly 20% of all Medicare discharges had a readmission within 30 days. In an effort to address this issue, the Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012 to positively influence readmissions associated with acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and total hip and/or knee arthroplasty. However, as recently as 2018, there were still 3.8 million 30-day all-cause adult hospital readmissions, with a 14% readmission rate and an average readmission cost of $15,200. The ACA also produced the Hospital Value-Based Purchasing (HVBP) program with the stated intent to (1) reduce mortality and complications, (2) reduce healthcare-associated infections, (3) increase patient safety, (4) improve the patient experience, and (5) increase efficiency and reduce costs. Given the costs and quality implications of an average readmission, it is logical to believe that HVBP eligible hospitals are simultaneously seeking to meet the goals of both programs. However, to date, no studies have examined if that is the case. Thus, in this study, we seek to determine if HVBP eligible hospitals are associated with a reduction in the core set of HRRP readmission rates better than the facilities that are not eligible for the HVBP program.

Methods

Hospital-level data from calendar year 2019 for 3,276 short-term acute care hospitals in the United States were evaluated using multivariate regression analysis to examine the readmission rate performance between 2,719 HVBP eligible hospitals and 557 ineligible hospitals.

Results

Our six separate multivariable linear regressions revealed a statistically significant and positive association between HVBP participation and readmission rates after controlling for numerous organizational, clinical complexity, and environmental factors. In each case, the magnitude of the positive directional association is moderate, ranging from and increase of +0.19% (pneumonia readmissions) to as high as +0.37% (all cause readmissions) for HVBP eligible hospitals. When considered in the context of the average number of discharges in our data set (x- = 9570), a third of a percent increase from the average 15.56% all cause readmissions to 16.08% in HVBP eligible hospitals equates to 50 additional readmissions annually (9570 × 15.56% = 1,489 vs 9570 × 16.08% = 1,539). At an average cost of $15,200 per readmission, which equates to an average additional cost to the average HVBP eligible hospital in excess of $760,000.

Discussion

The fact that there is a positive association between HVBP participating hospitals and readmissions at all, and that the same effect appears to be persistent across all dependent measures is concerning. One would logically expect hospitals that are focused on quality-based care to thoroughly care for individuals in order for them to not be readmitted to the hospital. The results provided do not necessarily prove that either program is not working. But they also do not confirm that the HVBP and HRRP programs are working together and accomplishing what they were originally designed to do: improve patient care and lower health-care costs.

Evaluating the robustness of the CMS Hospital Value-Based Purchasing measurement system

BACKGROUND

The Hospital Value-Based Purchasing Program (HVBP) is a pay for performance system that impacts traditional Medicare fee-for-service payments to hospitals through rewards and penalties.

OBJECTIVES

To explore variation in overall and individual-hospital total performance score (TPS) and embedded domains for hospitals during 2014-2018.

DATA SOURCE

Hospital data were retrieved from the publicly available HOSArchive dataset.

STUDY DESIGN

Distribution of annual TPS and HVBP domain scores for 2014-2018 was evaluated using descriptive statistics. Transitional probabilities were analyzed to evaluate annual movement in the TPS ranking for outlier hospitals in the Top and Bottom 5%.

PRINCIPAL FINDINGS

TPS scores are positively skewed while the distribution of domain scores vary with patient experience, (clinical) outcome, and efficiency domains having a large number of (positive) outliers. Mean TPS score decreased from 40.54 in 2014 to 38.04 by 2018. Improvement was shown in mean domain scores for clinical process of care and clinical outcome using 95% confidence intervals, with hospitals gaining 10 points over the study period in clinical outcome. Changes in the mean scores for other domains did not show consistent increases or decreases. Chi-square analyses of hospital ranking categories showed some evidence that, as a group, hospitals initially ranked in the Bottom 5% are making consistent annual movements to higher categories. In contrast, over half of the hospitals ranking in the initial Top 5% remained in the top category across all study years.

CONCLUSIONS

It may be time for CMS to redesign the HVBP incentive program to assure the measures accurately demonstrate sustained improvement, the domain weights appropriately reflect the level of importance, and the TPS comparative ranking methodology does not discourage lower-performing hospitals from actively improving the care they deliver and achieving top ranks.

Hospital Performance in the First 6 Years of Medicare's Value-Based Purchasing Program

The Medicare value-based purchasing (VBP) program, ongoing since 2013, uses financial bonuses and penalties to incentivize hospital quality improvements. Previous research has identified characteristics of penalized hospitals, but has not examined characteristics of hospitals with improvements in VBP program performance or consistent good performance. We identify five different trajectories of program performance (improvement, decline, consistent good or poor performance, mixed). A total of 11% of hospitals were penalized every year of the program, 24% improved their VBP program performance, 14% of hospitals consistently earned a bonus, while 18% performed well in the program's early years but experienced declines in performance. In 2013, organizational and community characteristics were associated with higher odds of improving relative to performing poorly every year. Few variables under managers' control were associated with program improvement, though accountable care organization participation was in some models. We find changes in VBP program metrics may have contributed to improvement in some hospitals' program scores.

Limitations of patient experience reports to evaluate physician quality in spine surgery: analysis of 7485 surveys

OBJECTIVE

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) is a standardized patient experience survey that is used to evaluate the quality of care delivered by physicians. The authors sought to determine which factors influenced CG-CAHPS scores for spine surgery, and compare them to their cranial-focused cohorts.

METHODS

A retrospective study of prospectively obtained data was performed to evaluate CG-CAHPS scores. Between May 2013 and May 2017, all patients 18 years of age or older with an outpatient encounter with a neurosurgeon (5 spine-focused neurosurgeons and 20 cranial-focused neurosurgeons) received a CG-CAHPS survey. Three domains were assessed: overall physician rating, likelihood to recommend, and physician communication. Statistical analyses were performed using chi-square tests.

RESULTS

Seven thousand four hundred eighty-five patient surveys (2319 spine and 5166 cranial) were collected from patients presenting to the outpatient offices of an attending neurosurgeon. Analysis of the overall physician rating showed that 81.1% of spine neurosurgeons received a "top-box" score (answers of "yes, definitely"), whereas 86.2% of cranial neurosurgeons received a top-box response (p < 0.001). A similar difference was observed with the domains of "likelihood to recommend" and "physician communication." Overall physician rating was also significantly influenced by the general and mental health of the patients surveyed (p < 0.001). For spine surgeons seeing patients at more than one facility, the scores with respect to location were also significantly different in all domains for each individual provider (p < 0.001).

CONCLUSIONS

Overall, spine-focused neurosurgeon ratings differed significantly from those of cranial-focused neurosurgical subspecialty providers. Office location also affected provider ratings for spine neurosurgeons. These results suggest that physician ratings obtained via patient experience surveys may be representative of factors aside from just the quality of physician care provided. This information should be considered as payers, government, and health systems design performance programs based on patient experience scores.

Resource Dependency and Hospital Performance in Hospital Value-Based Purchasing

To help influence the health care environment as well as the flow of resources into and out of hospitals, the Centers for Medicare & Medicaid Services has implemented a performance incentive initiative called the Hospital Value-Based Purchasing (HVBP) program. As such, this study utilizes the lens of Resource Dependency Theory to evaluate the effect of the external environment on hospital performance as measured by the HVBP program. This study utilizes data from the 2014 American Hospital Association (AHA) Annual Survey database, 2014 Area Health Resource File (AHRF), the 2014 Medicare Final Rule Standardizing File, and the 2014 Medicare Hospital Compare database. The associations between external environment and hospital performance are assessed through multiple regression analysis. Hospital performance scores in the HVBP program are sensitive to environmental factors; however, not all domains are influenced to the same degree. It would seem that hospitals do not have either the same ability or motivation to make changes in each of the value-based purchasing domains. Ultimately, the findings from this study indicate that environmental forces do play a role in hospitals' performance in the HVBP program.

Does Hospital Size Affect Patient Satisfaction?

BACKGROUND

Centers for Medicare & Medicaid Services reimbursement is now contingent on quality measures such as patient satisfaction as determined by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). In providing patient-centered care that is guided by patient satisfaction measures, it is critical to understand system-level factors that may influence how patients assess their care experiences. One important system-level influence to consider is hospital size.

METHODS

HCAHPS scores, number of hospital beds, and nursing magnet status were obtained from publically available Hospital Compare, American Hospital Directory, and Magnet Hospitals Web sites, respectively. An aggregate score for patient satisfaction was created across all domains of the HCAHPS. Multilevel regression modeling was performed to examine the associations between hospital size and HCAHPS aggregate and individual dimensions.

RESULTS

Hospital size was significantly associated with patient satisfaction such that larger size was associated with lower satisfaction (β = -.312, P < .001). Hospital size was most strongly associated with less patient satisfaction on the following HCAHPS items: "receiving help as soon as needed" (β = -.441, P < .001), "room and bathroom cleanliness" (β = -.286, P < .001), and doctor communication (β = -.213, P < .001), whereas nurse communication (β = .194, P < .001) was the one modifiable dimension that was associated with more favorable ratings in larger hospitals. Magnet nursing designation was significantly associated with larger hospital size (P < .001).

CONCLUSION

Patient satisfaction scores may be lower in large hospitals because of patients' perceptions of hospital cleanliness, receiving help on time, and doctor communication. Focusing on improving these factors may improve patient satisfaction scores for larger hospitals.

Measuring Value in Internal Medicine Residency Training Hospitals Using Publicly Reported Measures

Graduate medical education (GME) lacks measures of resident preparation for high-quality, cost-conscious practice. The authors used publicly reported teaching hospital value measures to compare internal medicine residency programs on high-value care training and to validate these measures against program director perceptions of value. Program-level value training scores were constructed using Centers for Medicare & Medicaid Services Value-Based Purchasing (VBP) Program hospital quality and cost-efficiency data. Correlations with Association of Program Directors in Internal Medicine Annual Survey high-value care training measures were examined using logistic regression. For every point increase in program-level VBP score, residency directors were more likely to agree that GME programs have a responsibility to contain health care costs (adjusted odds ratio [aOR] 1.18, P = .04), their faculty model high-value care (aOR 1.07, P = .03), and residents are prepared to make high-value medical decisions (aOR 1.07, P = .09). Publicly reported clinical data offer valid measures of GME value training.

Predictors of Satisfaction With Doctor and Nurse Communication: A National Study

Prior research indicates that effective communication between medical providers and patients is associated with a number of positive patient outcomes, yet little research has examined how ecological factors (e.g., hospital size, local demographics) influence patients' reported satisfaction with doctor and nurse communication. Given the current emphasis on improving patient satisfaction in hospitals across the United States, understanding these factors is critical to interpreting patient satisfaction and improving patient-centered communication, particularly in diverse and dense populations. As such, this study examined county-level data including population density, population diversity, and hospital structural factors as predictors of patient satisfaction with doctor and nurse communication. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), U.S. Census data, and number of hospital beds were obtained from publicly available Hospital Compare, U.S. Census, and American Hospital Directory websites, respectively. Multivariate regression modeling was performed for the individual dimensions of HCAHPS scores assessing doctor and nurse communication. Standardized partial regression coefficients were used to assess strengths of county-level predictors. County-level factors accounted for 30% and 16% of variability in patient satisfaction with doctor and nurse communication, respectively. College education (β = 0.45) and White ethnicity (β = 0.25) most strongly predicted a favorable rating of doctor and nurse communication, respectively. Primary language (non-English speaking; β = -0.50) most strongly predicted an unfavorable rating of doctor communication, while number of hospital beds (β = -0.16) and foreign-born (β = -0.16) most strongly predicted an unfavorable rating of nurse communication. County-level predictors should be considered when interpreting patient satisfaction with doctor and nurse communication and designing multilevel patient-centered communication improvement strategies. Discordant findings with individual-level factors should be explored further.

The Influence of Hospital Market Competition on Patient Mortality and Total Performance Score

The Affordable Care Act of 2010 launch of Medicare Value-Based Purchasing has become the platform for payment reform. It is a mechanism by which buyers of health care services hold providers accountable for high-quality and cost-effective care. The objective of the study was to examine the relationship between quality of hospital care and hospital competition using the quality-quantity behavioral model of hospital behavior. The quality-quantity behavioral model of hospital behavior was used as the conceptual framework for this study. Data from the American Hospital Association database, the Hospital Compare database, and the Area Health Resources Files database were used. Multivariate regression analysis was used to examine the effect of hospital competition on patient mortality. Hospital market competition was significantly and negatively related to the 3 mortality rates. Consistent with the literature, hospitals located in more competitive markets had lower mortality rates for patients with acute myocardial infarction, heart failure, and pneumonia. The results suggest that hospitals may be more readily to compete on quality of care and patient outcomes. The findings are important because policies that seek to control and negatively influence a competitive hospital environment, such as Certificate of Need legislation, may negatively affect patient mortality rates. Therefore, policymakers should encourage the development of policies that facilitate a more competitive and transparent health care marketplace to potentially and significantly improve patient mortality.

Admission Through the Emergency Department Is an Independent Risk Factor for Lower Satisfaction With Physician Performance Among Orthopaedic Surgery Patients: A Multicenter Study

BACKGROUND

Patient experience data are increasingly used to guide performance improvement and to determine physician and hospital reimbursement. We studied the relationship between emergency department (ED) admission and patient satisfaction with physicians' performance, and identified other associated predictors.

METHODS

We evaluated 6,524 inpatient Press Ganey patient experience surveys from two academic level I trauma centers over 5 years. We stratified patients by ED admission or other admission and compared the proportions of patients in each group who were satisfied with physician performance. We used logistic regression to control for demographic differences and characteristics of hospitalizations.

RESULTS

Among patients admitted through the ED, 85.18% were satisfied, compared with 89.44% of patients admitted through other pathways (P < 0.001). Admission through the ED predicted decreased satisfaction, with an odds ratio of 0.67 (P = 0.032) after controls were applied through logistic regression.

CONCLUSIONS

Admission through the ED is an independent risk factor for lower satisfaction with physician performance. Understanding the determinants of patient satisfaction will help improve physician-patient interactions and guide quality improvement and value-based reimbursement initiatives.

LEVEL OF EVIDENCE

This retrospective survey-based analysis of satisfaction does not fall clearly under any of the Journal's established categories of level of evidence. The most closely aligned choice would be Level III Prognostic.

Who presents satisfied? Non-modifiable factors associated with patient satisfaction among gynecologic oncology clinic patients

OBJECTIVE

To examine associations between non-modifiable patient factors and patient satisfaction (PS) among women presenting to a gynecologic oncology clinic.

METHODS

This is a cross sectional analysis of patients presenting for surgical management by a gynecologic oncologist at a tertiary care academic medical center. The Patient Satisfaction Questionnaire (PSQ-18) that measures PS in seven domains of health care was administered. Scores were converted to "satisfied" versus "unsatisfied/equivocal". Demographic and medical factors were obtained from the medical record. Chi-square, t-tests, and multivariable logistic regression were used.

RESULTS

208 patients completed the baseline patient satisfaction questionnaire and the median PSQ-18 score was 70.5 (range: 42-90). Median age was 58years (range: 22-93). Several non-modifiable factors were associated with PS. White patients had higher interpersonal PS than minorities (86% v 65%, p=0.002). The uninsured had lower interpersonal (60% v 86%, p=0.003) and accessibility PS (33% v 67%, p=0.03). Increasing education and less time travelled to care were both associated with higher interpersonal (p=0.03, p=0.05) and accessibility PS (p=0.01, p=0.01). There was no association between clinical factors (BMI, comorbidities, cancer) and PS. In multivariable analysis, the strongest predictor of interpersonal PS was white race while the strongest predictors of accessibility PS were time travelled to care and insurance status.

CONCLUSIONS

Patient satisfaction scores among patients presenting to a gynecologic oncology clinic are associated with non-modifiable demographic, financial and geographic factors. Pay for performance measures that use summed patient satisfaction scores may penalize hospitals for patient-mix driven differences.

The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital.

METHODS

We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge.

RESULTS

Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen.

CONCLUSION

An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.

Demographic factors and hospital size predict patient satisfaction variance--implications for hospital value-based purchasing

BACKGROUND

Hospital Value-Based Purchasing (HVBP) incentivizes quality performance-based healthcare by linking payments directly to patient satisfaction scores obtained from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Lower HCAHPS scores appear to cluster in heterogeneous population-dense areas and could bias Centers for Medicare & Medicaid Services (CMS) reimbursement.

OBJECTIVE

Assess nonrandom variation in patient satisfaction as determined by HCAHPS.

DESIGN

Multivariate regression modeling was performed for individual dimensions of HCAHPS and aggregate scores. Standardized partial regression coefficients assessed strengths of predictors. Weighted Individual (hospital) Patient Satisfaction Adjusted Score (WIPSAS) utilized 4 highly predictive variables, and hospitals were reranked accordingly.

SETTING

A total of 3907 HVBP-participating hospitals.

PATIENTS

There were 934,800 patient surveys by the most conservative estimate.

MEASUREMENTS

A total of 3144 county demographics (US Census) and HCAHPS surveys.

RESULTS

Hospital size and primary language (non-English speaking) most strongly predicted unfavorable HCAHPS scores, whereas education and white ethnicity most strongly predicted favorable HCAHPS scores. The average adjusted patient satisfaction scores calculated by WIPSAS approximated the national average of HCAHPS scores. However, WIPSAS changed hospital rankings by variable amounts depending on the strength of the predictive variables in the hospitals' locations. Structural and demographic characteristics that predict lower scores were accounted for by WIPSAS that also improved rankings of many safety-net hospitals and academic medical centers in diverse areas.

CONCLUSIONS

Demographic and structural factors (eg, hospital beds) predict patient satisfaction scores even after CMS adjustments. CMS should consider WIPSAS or a similar adjustment to account for the severity of patient satisfaction inequities that hospitals could strive to correct.

Factors associated with patient satisfaction scores for physician care in trauma patients

BACKGROUND

The Affordable Care Act of 2010 identifies "patient experience of care" as one of five domains of excellent care. We hypothesized that there are specific demographic factors associated with higher or lower physician satisfaction (PS) scores in trauma patients.

METHODS

Press-Ganey PS scores for September 2004 to December 2010 were compared with trauma variables and the association of a mean PS greater than or equal to 75 (high score) or less than or equal to 50 (low score). Those variables that proved significant on univariate analysis were subjected to multivariate logistic regression analysis. Significance was at p < 0.05.

RESULTS

There were 12,196 admissions, of whom 1,631 (13.4%) returned patient satisfaction survey. A total of 1,174 patients (75.5%) returned a high PS (≥75), and 126 patients (8.1%) returned a low PS (≤50). In the multiple logistic regression analysis, 65 years or older (odds ratio [OR], 1.7), having had a surgical procedure (OR, 1.6), and having a positive impression of the hospital care (OR, 7.0) proved significant for a high PS. Those patients who scored a low PS were significantly more likely to be younger (18-29 years: OR, 2.4; 30-64 years: OR, 1.8), to have not had surgery (OR, 2.2), had an Injury Severity Score (ISS) of 16 or lower (OR, 2.6), had a complication of care (OR, 4.4), and rated the hospital care as poor (OR, 9.2).

CONCLUSION

A trauma patient who is satisfied with his or her physician care is one who is 65 years or older, requires surgery, and is predominantly satisfied with other aspects of their hospital care. Unsatisfied patients are younger, are nonoperative, had lower ISS, had a complication of care, and rated their hospital care as poor. Understanding the specific characteristics of Press-Ganey results for trauma patients will allow trauma surgeons and their hospital partners to develop strategies to improve patients' satisfaction with their trauma surgeon's care.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.