Validating P4P Improvement: The Data Is In

Bankowitz: That’s right, the studies seem to suggest that resource-poor hospitals can improve. Part of this is that there’s a recognition that hospitals really need to address systems of care. A lot of these measures, which are based on evidence-based practices, tend to respond very well to putting in place systems that eliminate the variation that occurs. And the focus that something like the measurement provides, is really the key. And I do think that the financial rewards play some role. We’ve found in our own internal studies, when we’ve looked at those receiving a financial reward, by the third year, there really was no difference between the disproportionate-share hospitals [DSH], and the non-DSH. In the first year of HQID, there were relatively few DSH hospitals participating, but by the third year, their level of participation matched their representation in the industry.

We did find that the level of recognition was different. Our guess was that in some cases, hospitals might be motivated by getting the financial reward, but less so by the chance to get public recognition. Also, being involved in the program itself meant that these hospitals were able to access information on best practices, and we were able to share with them what the best hospitals were doing, so it didn’t require reinventing the wheel. So I think if there’s a combination of sharing with best practices, they can catch up pretty quickly.

HCI: Is there any cultural element to this that has to be addressed in these hospitals, in terms of serving largely uneducated and impoverished populations?

Bankowitz: It’s an interesting question, and I don’t think we have any hard and fast data. But when you start looking beyond data around mortality, and towards data around questions like readmissions, I think that certainly must be a factor. It’s well known that the level of medical literacy is going to vary greatly; and those individuals who aren’t as medically literate may not understand as readily the importance of taking one’s medications, for example. And if you look at some populations and the numbers of prescriptions that don’t get filled, sometimes it’s as high as 40 percent; and if you look at areas in which that is the case, such as asthma, where ED visits or admissions are higher, certainly, whatever socioeconomic factors are at play, they’re going to show up in the ED with greater frequency. In this case, it’s a little bit different, though, because most of the processes under study are under the direct control of the caregiver, in terms of ordering aspirin after a heart attack and so forth. But obviously, in terms of issues like outcomes around complications and readmissions, those factors come into play.

HCI: What does this Annals of Internal Medicine study say about the overall robustness of P4P programs?

Bankowitz: Well, a couple of things. First of all, incentives do work. And whether it involves getting recognized as a high-performing hospital or obtaining the funding, incentives do matter. At the very beginning of the HQID program, adherence to best practices in many areas was abysmal. Look at pneumonia care: improvement in that area [since then] has been tremendous. And overall, we’ve seen dramatic and sustained improvement after several years of HQID. And even though the incentives have been relatively small, we’ve asked some of the hospitals about the resources expended, and they’ll say, we did get the money, but we’ve probably spent more resources accomplishing the goals involved. But these incentives get the chief medical officer and the chief financial officer aligned, for the first time. And so now we can have a conversation for the business case for this; and that’s an important conversation.

HCI: Value-based purchasing was incorporated into the federal healthcare reform legislation passed in March. Did the provisions around value-based purchasing in that legislation reflect the HQID program’s modeling work in that area?