Luck of the draw: Role of chance in the assignment of medicare readmissions penalties

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare’s Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals’ 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.

Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates

<p>Objective : To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs). </p> <p>Design : Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP–augmented strategies of the P-PROMPT reminder and recall system. </p> <p>Setting : Southwestern Ontario. </p> <p>Participants : A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives. </p> <p>Interventions : The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services. </p> <p>Main outcome measures : The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months. </p> <p>Results : Before-and-after comparisons of time-appropriate delivery rates (<30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P >< .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services. </p> <p>Conclusion : The use of provider and patient reminders and pay-forperformance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.</p>

Proximity to Heavy Traffic Roads and Patient Characteristics of Late of Onset Asthma in an Urban Asthma Center

Background: Traffic-related pollution is associated with the onset of asthma and the development of different phenotypes of asthma. Few studies have investigated the association between traffic proximity and late-onset of asthma (LOA) and early-onset asthma (EOA). This study was conducted to investigate the associations of LOA phenotypes with a function of the distance between residence and heavy traffic roads (HTRs).Methods: The study group consisted of 280 patients who were (LOA: 78.4%) recruited consecutively from a pay-for-performance asthma program to clarify the patient characteristics and proximity to HTRs within 1,000 m from their residences between EOA and LOA in three urban centers in Taiwan. The subsequent analysis focused on patients with LOA (n = 210) linking phenotypes and distance to HTRs.Results: Subjects with LOA tended to be older than those with EOA and had shorter asthma duration, poorer lung function, lower atopy, and less exposure to fumes or dust at home. Patients with LOA were more likely than those with EOA to live within 900 m of two or more HTRs (14.3 vs. 3.4%, p = 0.02). Among patients with LOA, minimum distance to an HTR was negatively associated with numbers of specific IgE as well as positively associated with the age of onset and body weight significantly. A higher proportion of patients with atopy (26.3 vs. 20.6%, p = 0.001. odds ratio [OR]: 2.82) and anxiety/depression (21.0 vs. 18.1%, p = 0.047. OR: 1.81) and a trend of lower proportion of patients with obese (5.7 vs. 12.4%, p = 0.075) were found to be living within 900 m from HTRs.Conclusions: Late-onset of asthma (LOA) tended to live in areas of higher HTR density compared to EOAs. Among patients with LOA living close to HTRs, the interaction between traffic-related pollution, allergy sensitization, and mood status were the factors associated with asthma onset early. Obesity may be the factor for later onset who live far from HTRs.

COVID-19 and Person-Centered Care: Lessons Learned Through a Statewide Program for Nursing Homes

Frail elders in nursing homes are the highest risk group for developing complications of COVID-19. This lead to a response from CMS and state regulators that was heavily focused on protection and safety through segregation and infection control. The purpose of this study was to gather the narrative of this pandemic response and understand the impact on person-centered care and be able to address provider needs in real-time. This qualitative method focused on nursing home providers who are a part of PEAK 2.0, a Medicaid pay-for-performance program in Kansas. Interviews with nursing home staff (n=168) revealed two critical themes of need; mandated responses disregarded elders’ autonomy and self-determination in decision making, and infection control strategies required new approaches to facets of resident care that still maintained dignity. This data, along with COVID-19 guidance were then used to inform feasible resource development and education to maintain PCC practices during the pandemic.

Impact of global budget combined with pay-for-performance on the quality of care in county hospitals: a difference-in-differences study design with a propaensity-score-matched control group using data from Guizhou province, China

Background Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China. Methods Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases. Results After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality. Conclusions The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.

Association of pre-ESRD care education with patient outcomes in a 10-year longitudinal study of patients with CKD stages 3–5 in Taiwan

There is little comprehensive education for people with end-stage renal disease (ESRD) progress. We investigated the differences in terms of outcomes between patients with CKD stages 3–5 who enrolled and did not enroll in the pre-ESRD care education in Taiwan. This retrospective cohort study was conducted using data from the National Health Insurance Research Database (NHIRD). All patients diagnosed with CKD stages 3–5 who received the pre-ESRD care education through the pay for performance (P4P) program were enrolled. Based on whether or not they participated in the program, they were categorized into P4P or non-P4P groups. All analyses were performed from January 2006 through December 2015. Study outcomes were risk of hemodialysis dependency, hospitalization, and all-cause mortality. In this study of 29,337 patients, those with CKD stages 3–5 in the P4P group had lower events of hemodialysis, hospitalization, and all-cause mortality compared to patients in the non-P4P group. This study suggested that pre-ESRD care education is associated with increased patient outcomes, resulting in lower hemodialysis and hospitalization events and a higher overall survival rate in patients with CKD stages 3–5. Patient education could raise opportunities to improve pre-ESRD care by reaching patients outside the traditional health care setting.

The Effectiveness of Pay-for-Performance Program of Diabetes Care for Psychiatric Patients: A Regional Psychiatric Hospital Experience

Background: The Pay-for-performance (P4P) program of diabetes care has demonstrated successful outcomes in patients with type 2 diabetes. However, the effectiveness of this multidisciplinary care model for psychiatric patients has never been evaluated. The objective of this study is to examine the effectiveness of P4P program of diabetes for psychiatric patients with diabetes. Methods: This study utilized a retrospective cohort design to examine the effectiveness of P4P program of diabetes care for psychiatric patients with diabetes. The participants’ HbA1c (hemoglobin A1c) data of the fourth quarter in 2018 were used as baseline value, while P4P program was not applied yet. HbA1c data of every quarter in 2019 were collected. Generalized estimating equations (GEE) was used to analyze the change of HbA1c level. Results: The HbA1c level increased slightly in the first quarter, and then decreased gradually since the second quarter. The HbA1c level was significantly lower in the fourth quarter after P4P program intervention (p < 0.05). Conclusion: P4P program of diabetes care is also effective on psychiatric patients with diabetes, and this multidisciplinary care model could be encouraged and promoted for psychiatric patients with diabetes.

Pay-for-performance in primary health care: A comparative study of health policymaking in England and New Zealand

<p>England and New Zealand introduced pay-for-performance schemes in their primary health care systems, with incentives for general practitioners to achieve improved population-based health outcomes, between 2001 and 2007. These schemes were part of health reforms to change the relationship between the state and the medical profession, giving the state increased influence over the quality and allocation of publicly funded health care. Two schemes of differing size, scope and impact were implemented. This research takes a comparative approach to exploring each policymaking process, utilising quasi-natural experimental conditions in these two Westminster governing systems to test the relevance of Kingdon’s multi-theoretic Multiple Streams Framework and other theoretical approaches to explain policy variation and change. The research documented and analysed the agenda-setting, alternative selection and implementation phases in the two policymaking processes and identified the key drivers of policymaking in each case study. A qualitative methodology, based upon documentary analysis and semi-structured interviews with 26 decision-makers, leaders and participants, was used to develop the two case studies, providing rich descriptive details and rare insights into closed policymaking approaches as seen by the participants. From this case study evidence, themes were drawn out and reviewed for consistency with Kingdon’s Multiple Streams Framework as it has been interpreted and adapted by Zahariadis. The case study evidence and themes were considered in a framework of comparative analysis where patterns of similarity and difference were established. The utility of Kingdon’s Multiple Streams Framework in interpreting the case study evidence was assessed. This analysis demonstrated that Kingdon’s Framework, as interpreted by Zahariadis, had high descriptive power for both case studies but failed to predict the patterns of non-incremental change observed or the importance of institutional factors such as ownership and governance arrangements for public services, interest group structure and historical antecedents seen in the two policymaking processes. The research finds that the use of bargaining in England and not in New Zealand is the reason for major differences in speed, scope and outcomes of the two pay-for-performance schemes. Institutional structures in the general practice sub-system are therefore the primary driver of policy change and variation. These acted as enablers of non-incremental change in the English case study, providing incentives for actors individually and collectively to design and rapidly to implement a large-scale pay-for-performance scheme. The institutional features of the general practice sub-system in New Zealand acted as a constraint to the development of a large-scale scheme although non-incremental change was achieved. Phased approaches to implementation in New Zealand were necessary and slowed the delivery of outcomes from the scheme. With respect to other drivers of policy change and variation, the role of individual actors as policy and institutional entrepreneurs was important in facilitating policy design in each country, with different types of entrepreneurs with different skills being observed at different stages of the process. These entrepreneurs were appointed and working within the bureaucracy to the direction of decision-makers in both countries. England and New Zealand shared ideas about the benefits of New Public Management approaches to public policymaking, including support for pay-for-performance approaches, and there was a shared positive socio-economic climate for increased investment in health services. The research provides evidence that Westminster governing systems are capable of purposeful and orderly non-incremental health policy change and that Kingdon’s Multiple Streams Framework, which theorises policy formation in conditions of ambiguity, needs to be enhanced to improve its relevance for such jurisdictions. Recommendations for its enhancement are made.</p>