Magnet Hospitals and 30-Day Readmission and Mortality Rates for Medicare Beneficiaries

BACKGROUND

US hospitals are penalized for excess 30-day readmissions and mortality for select conditions. Under the Centers for Medicare and Medicaid Services policy, readmission prevention is incentivized to a greater extent than mortality reduction. A strategy to potentially improve hospital performance on either measure is by improving nursing care, as nurses provide the largest amount of direct patient care. However, little is known as to whether achieving nursing excellence, such as Magnet status, is associated with improved hospital performance on readmissions and mortality.

OBJECTIVE

The purpose of this study was to examine the relationship between hospitals' Magnet status and performance on readmission and mortality rates for Medicare beneficiaries.

RESEARCH DESIGN

This is a cross-sectional analysis of Medicare readmissions and mortality reduction programs from 2013 to 2016. A propensity score-matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals.

SUBJECTS

The sample was comprised of 3877 hospitals.

MEASURES

The outcome measures were 30-day risk-standardized readmission and mortality rates.

RESULTS

Following propensity score matching on hospital characteristics, we found that Magnet hospitals outperformed non-Magnet hospitals in reducing mortality; however, Magnet hospitals performed worse in reducing readmissions for acute myocardial infarction, coronary artery bypass grafting, and stroke.

CONCLUSIONS

Magnet hospitals performed better on the Hospital Value-Based Purchasing Mortality Program than the Hospital Readmissions Reduction Program. The results of this study suggest the need for The Magnet Recognition Program to examine the role of nurses in postdischarge activities as a component of its evaluation criteria.

Power and Purchasing: Why Strategic Purchasing Fails

Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness.

CONTEXT

Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing.

METHODS

We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years.

FINDINGS

No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry.

CONCLUSIONS

Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.

A Framework to Prioritise Health Research Proposals for Funding: Integrating Value for Money

When making funding decisions, research organisations largely consider the merits (e.g. scientific rigour and feasibility) of submitted research proposals; yet, there is often little or no reference to their value for money. This may be attributed to the challenges of assessing and integrating value of research into existing research prioritisation processes. We propose a framework that considers both the merits of research and its value for money to guide health research funding decisions. A practical framework is developed based on current processes followed by funding organizations for assessing investigator-initiated research proposals, and analytical methods for evaluating the expected value of research. We apply the analytical methods to estimate the expected return on investment of two real-world grant applications. The framework comprises four sequential steps: (1) initial screening of applications for eligibility and completeness; (2) merit assessment of eligible proposals; (3) estimating the expected value of research for the shortlisted proposals that pass the first two steps and ranking of proposals based on return on investment; and (4) selecting research proposals for funding. We demonstrate how the expected value for money can be efficiently estimated using certain information provided in funding applications. The proposed framework integrates value-for-money assessment into the existing research prioritisation processes. Considering value for money to inform research funding decisions is vital to achieve efficient utilisation of research budgets and maximise returns on research investments.

An Organization-Specific and Modifiable Inpatient Safety Composite Measure

In early 2013, seeking to apply the principles of value-based purchasing to all Kaiser Permanente hospitals as part of an existing organizationwide value-based performance incentive plan, Kaiser Permanente developed an inpatient safety composite measure that tracks hospital-level performance improvement related to 10 key inpatient safety events. The elements of the composite are weighted equally, and the tool draws on scoring methodologies used by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services Hospital Inpatient Value-Based Purchasing Program. Two years after implementation of the composite measure, hospitals experienced improvement across 9 of the 10 adverse events assessed, though only one improvement achieved statistical significance. The measure successfully distinguishes four levels of improvement and is broadly applicable to hospitals and hospital systems.

Moneyball in Medicare

US policymakers place high priority on tying Medicare payments to the value of care delivered. A critical part of this effort is the Hospital Value-based Purchasing Program (HVBP), which rewards or penalizes hospitals based on their quality and episode-based costs of care and incentivizes integration between hospitals and post-acute care providers. Within HVBP, each patient affects hospital performance on a variety of quality and spending measures, and performance translates directly to changes in program points and ultimately dollars. In short, hospital revenue from a patient consists not only of the DRG payment, but also of that patient's marginal future reimbursement. We estimate the magnitude of the marginal future reimbursement for individual patients across each type of quality and performance measure. We describe how those incentives differ across hospitals, including integrated and safety-net hospitals. We find evidence that hospitals improved their performance over time in the areas where they have the highest marginal incentives to improve care, and that integrated hospitals responded more than non-integrated hospitals.

Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency

BACKGROUND

The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency.

OBJECTIVE AND METHOD

While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015.

RESULTS

The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs.

CONCLUSION

The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.

How Can Health System Efficiency Be Improved in Canada?

Improving value for money in the health system is an often-stated policy goal. This study is the first to systematically measure the efficiency of health regions in Canada in producing health gains with their available resources, and to identify the factors that are associated with increased efficiency. Based on the objective elicited from decision-makers that the health system should ensure access to care for Canadians when they need it, we measured the efficiency with which regions reduce causes of death that are amenable to healthcare interventions using a linear programming approach (data envelopment analysis). Variations in efficiency were explained in part by public health factors, such as the prevalence of obesity and smoking in the population; in part by characteristics of the population, such as their average income; and in part by managerial factors, such as hospital readmissions.

Potential role of network meta-analysis in value-based insurance design

OBJECTIVES

Value-based insurance design (V-BID) has emerged as an approach to improve health outcomes and contain healthcare costs by encouraging use of high-value care. We estimated the impact of a V-BID for osteoporosis treatments using comparative effectiveness evidence and real-world data from a California health insurance plan to estimate the benefits of the design's implementation.

METHODS

This study consisted of 4 steps. First, we reviewed randomized clinical trials including osteoporosis treatments-alendronate, ibandronate, risedronate, raloxifene, and teriparatide-reported in a recent Agency for Health Research Quality systematic review. Second, we performed a network meta-analysis to synthesize data from the clinical trials and estimate the comparative effectiveness of included treatments. Third, we implemented a V-BID by removing co-payments for the most effective treatments. Fourth, using a Monte Carlo simulation, we estimated the impact of the V-BID in terms of fracture reduction and cost-savings.

RESULTS

Thirty-two randomized controlled trials were included in the network meta-analysis. We estimated that alendronate, risedronate, and teriparatide have the highest probability of being most effective across each fracture type-vertebral, hip, and nonvertebral/ nonhip. After eliminating co-payments, (ie, reducing them to zero), for these treatments, we estimated the health plan would experience a 7% (n = 287) decrease in fractures and an 8% ($6.8 million) decrease in costs.

CONCLUSIONS

Our study illustrates the benefits of comparative effectiveness evidence in V-BID development. We show that where clinical trials are lacking, network meta-analysis can provide valuable insights into the potential clinical and economic benefits of V-BID.

A systematic review of value-based insurance design in chronic diseases

OBJECTIVES

Value-based insurance design (V-BID) is an insurance cost-sharing model in which patients pay less for medications deemed to be of higher value. Our objective was to determine the association between V-BID and medication adherence, clinical outcomes, healthcare utilization, and spending in patients with or at risk for cardiovascular chronic diseases, compared with no differential lowering of drug co-payments.

STUDY DESIGN

Systematic review.

METHODS

We searched PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Controlled Trials Register, Current Controlled Trials, and reference lists of included studies and relevant reviews up to September 2012. Two reviewers independently identified primary research studies with the following study designs: randomized controlled trial, interrupted time series, and controlled before-after studies. Two reviewers independently extracted data and assessed quality.

RESULTS

Ten studies were identified: 1 high-quality randomized controlled trial, 1 interrupted time series analysis, and 8 controlled before-and-after studies. Heterogeneity in study populations and interventions, overall low study quality, and lack of standard error reporting precluded meta-analysis. All reported improvement in medication adherence for medications subject to V-BID, of between 2 and 5 percentage points. Impact on clinical outcomes was unclear, with only 1 study reporting on this, noting no difference in the primary outcome, but a reduction in adverse secondary outcomes with V-BID. Of the four studies that examined the impact of VBID on healthcare expenditures, V-BID tended to increase overall prescription drug spending, though three of the four studies reported similar overall healthcare costs due to decreased non drug medical spending.

CONCLUSIONS

V-BID is associated with improved medication adherence but its effects on clinical outcomes, healthcare utilization, and spending remain uncertain.

Using clinically nuanced cost sharing to enhance consumer access to specialty medications

With specialty pharmaceutical prices on the rise, patients are often expected to pay anywhere from 30% to 50% of the specialty-tier drug price through co-insurance-based cost sharing. As these prices continue to climb, patients may choose lower-value medications for their medical needs or become nonadherent for cost-related reasons. Value-based insurance design implementations for specialty medications connect cost sharing and clinical value by moving high-value medications into lower-priced tiers, adjusting cost-sharing based on patient-specific variables, applying the "reward the good soldier" strategy, and encouraging patients to seek high-performing providers.

Hospital value-based purchasing (VBP) program: measurement of quality and enforcement of quality improvement

VBP program is a novel medicare payment estimatin tool used to encourage clinical care quality improvement as well as improvement of patient experience as a customer of a health care system. The program utilizes well established tools of measuring clinical care quality and patient satisfaction such as the hospital IQR program and HCAHPS survey to estimate Medicare payments and encourage hospitals to continuosly improve the level of care they provide.

Ten practice redesign approaches

As healthcare delivery continues to evolve at a rapid pace, practices need to consider redesign approaches to stay ahead of the pack. From national policy and private payer initiatives to societal macro trends and the growing use of mobile technologies, delivering value, understanding customer needs, and assessing satisfaction are important elements to achieve and maintain success. This article discusses 10 practice redesign approaches.

Encouraging value-based insurance designs in state health insurance exchanges

OBJECTIVES

One of the main goals of the Affordable Care Act (ACA) is to control the costs of US healthcare. Channeling patients toward more effective services is one of many approaches being used to control costs while improving health outcomes. This paper reviews value-based insurance design (VBID) concepts and discusses options for states to encourage these designs in the new health insurance exchanges (HIEs).

METHODS

We reviewed the literature on VBID as well as the text of the ACA for descriptions of how VBID might be encouraged through the new state health insurance exchanges.

RESULTS

States, under healthcare reform, are allowed to promote the use of VBID designs in their exchanges. There are 4 broad approaches a state HIE could pursue with regard to VBID, ranging from establishing a process for recommending high- or low-value services and requiring plans to adhere to the recommendations, to offering no guidance to plans. The evidence surrounding how well VBID designs work is growing, but it is still limited. To date there is no evidence that reducing or eliminating copays for preventive services cuts costs in the long term. However, modeling does suggest the potential for such long-term savings,so states should proceed with caution.

CONCLUSIONS

Modifying copays, even in small amounts, can send signals to patients about the relative value of drugs and services. However, long-term savings will likely result from higher copays on low-value services. The leadership of each exchange has a unique opportunity to reshape the insurance benefit landscape in its state to improve value and invest in prevention.

Enhancing quality improvements in cancer care through CME activities at a nationally recognized cancer center

Changing healthcare policy will undoubtedly affect the healthcare environment in which providers function. The current Fee for Service reimbursement model will be replaced by Value-Based Purchasing, where higher quality and more efficient care will be emphasized. Because of this, large healthcare organizations and individual providers must adapt to incorporate performance outcomes into patient care. Here, we present a Continuing Medical Education (CME)-based initiative at the City of Hope National Cancer Center that we believe can serve as a model for using CME as a value added component to achieving such a goal.

Understanding and surviving the transition to value-based oncology

This paper and the three presentations it supports are drawn from the theme of the 2012 Cancer Center Business Summit (CCBS): "Transitioning to Value-Based Oncology: Strategies to Survive and Thrive." The CCBS is a forum on oncology business innovation, and the principal question the organizers address each year is "What are the creative, innovative, and best business models and practices that are being conceived or piloted today that may provide a responsible and sustainable platform for the delivery of cancer care tomorrow?" At this moment in health care-when so much is in flux and new business models and solutions abound-the oncology sector has a solemn responsibility: to forge the business models and relationships that will help to define a new cancer care value proposition and a sustainable health care system of tomorrow for the benefit of the patients it serves to get it "right."