by Sanaz Cordes, MD
As clinicians, we are all first and foremost scientists. We have been trained on the “scientific method” - to clearly understand the problem, the hypothesis, the interventions, the outcome, and the implications for future study. That has been drilled into us in school, in training, and in every piece of evidence that we lovingly read in our daily news feeds. We place so much emphasis on the evidence when it comes to treating our patients, however, I am not sure that we place enough emphasis on the evidence as it applies to our healthcare programs.
The Problem: Rising Healthcare Costs
National healthcare spending has been increasing every year. Recent results released by CMS at the end of 2016 show our national 2015 healthcare expenditure at $3.2 Trillion or $9,900 per person and accounting for 17.8% of GDP. As you might expect, the largest share of the bill is paid by the US government with Medicare picking up $646B and Medicaid paying for $545B. Close behind the US government in healthcare spending is the private insurance plans picking up $1,072B. In last place are the consumers, with a paltry of out of pocket spend of $338B.
The Intervention: Programs to Rein in Cost
With these huge dollars poured into healthcare, it is not surprising that CMS has implemented numerous programs to shift our payment system from fee-for-service to value-based care. Instead of paying hospitals and providers for the number of visits and tests they order, now payments are based on the value of care that they deliver. The value-based programs have included a variety of hospital programs including Hospital-Acquired Condition Reduction Program (HACRP), Hospital Readmissions Reduction Program (HRRP), and Hospital Value-Based Purchasing (HVBP) Program. As we head toward the new programs coming up this year, such as the Alternative Payment Models (APMs) and Merit-Based Incentive Payment Systems (MIPS), it is a good time to glance back at the programs that have been in place and consider how well they have been working.
The HVBP Program is one program that brings both quality of care and cost of care into the program. Hospitals in the program have 2% of their reimbursement withheld and then hospitals are gauged on measures such as mortality, HACs, patient safety, patient experience, efficiency, and cost reduction. Based on the hospitals' total performance score, they may earn back their 2% and have the opportunity to earn an additional 2%. At the moment, the program is cost neutral as far as healthcare expenditures, so the main question becomes: Is this financial incentive for hospitals really improving care?
Is HVBP Program Improving Outcomes?
A 2015 study looking at the early effects of the HVBP program compared 12 clinical processes and 8 patient experiences measures between hospitals enrolled in the program and hospitals excluded from the program. This study looked at a 1-year time period from 2011 to 2012. The study found no significant difference in any of the clinical processes or the patient experience measures during the first implementation period of the program. The authors concluded that the financial incentives were too low to incentivize hospitals or that the complicated design might not have given them a clear target. The results suggest that we have yet to find the right measures to improve clinical process and patient experience.
In 2016, a new study investigated if HVBP was indeed improving care by comparing mortality for AMI, heart failure, and pneumonia between hospitals participating in the program and hospitals excluded from the program. This study was conducted over a 5-year period from 2008-2013. The study found that mortality trends between the two groups was small and non-significant. In looking at subgroups of hospitals, including poor performers, there was still no association between HVBP Program participation and better outcomes. The authors concluded that we have yet to find the right quality metrics and incentives to improve patient outcomes.
The Bottom Line
As we apply the scientific method to the HVBP Program, one would question if the program is targeting the right outcomes or providing the right incentives? What interventions have the high performing hospitals implemented that may be contributing to their better outcomes? Are there other factors that CMS should be targeting? For example, hospital ownership and social determinants are now shown to play a role in improving outcomes, yet they are not currently factored in HVBP program design or measures. So, as any good scientist would conclude, the HVBP “experiment,” so far, is inconclusive. The scientific method would dictate that the next step is to put our subject back under the microscope and test new hypotheses.