The long-term effect of premier pay for performance on patient outcomes.

BACKGROUND Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes. METHODS We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009. RESULTS At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, -0.07 percentage points; 95% confidence interval [CI], -0.40 to 0.26). The rates of decline in mortality per quarter at the two types of hospitals were also similar (0.04% and 0.04%, respectively; difference, -0.01 percentage points; 95% CI, -0.02 to 0.01), and mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, -0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers at baseline, mortality was similar in the two groups of hospitals at the start of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI, -0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%; difference, -0.03 percentage points; 95% CI, -0.08 to 0.02) and similar mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15 percentage points; 95% CI, -0.70 to 1.01). CONCLUSIONS We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.

[1]  Fang-Shu Ou,et al.  Pay for performance, quality of care, and outcomes in acute myocardial infarction. , 2007, JAMA.

[2]  E. Stuart,et al.  The effect of pay-for-performance in hospitals: lessons for quality improvement. , 2011, Health affairs.

[3]  E. Hannan,et al.  Relationship between surgeon and hospital volume and readmission after bariatric operation. , 2007, Journal of the American College of Surgeons.

[4]  M. Rosenthal,et al.  Early experience with pay-for-performance: from concept to practice. , 2005, JAMA.

[5]  Hude Quan,et al.  Comparison of the Elixhauser and Charlson/Deyo Methods of Comorbidity Measurement in Administrative Data , 2004, Medical care.

[6]  E John Orav,et al.  The inverse relationship between mortality rates and performance in the Hospital Quality Alliance measures. , 2007, Health affairs.

[7]  P. Rosenbaum,et al.  Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. , 2007, JAMA.

[8]  Eric T. Bradlow,et al.  Relationship between Medicare's hospital compare performance measures and mortality rates. , 2006, JAMA.

[9]  L. Sandy,et al.  Pay for performance in commercial HMOs. , 2007, The New England journal of medicine.

[10]  Mph Ashish K. Jha MD,et al.  The Association Between Hospital Margins, Quality of Care, and Closure or Other Change in Operating Status , 2011, Journal of General Internal Medicine.

[11]  Laura Petersen,et al.  Does Pay-for-Performance Improve the Quality of Health Care? , 2006, Annals of Internal Medicine.

[12]  Kevin G Volpp,et al.  Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. , 2007, JAMA.

[13]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[14]  R. Berenson,et al.  Payment reform--the need to harmonize approaches in Medicare and the private sector. , 2010, The New England journal of medicine.

[15]  M. Rosenthal,et al.  What Is the Empirical Basis for Paying for Quality in Health Care? , 2006, Medical care research and review : MCRR.

[16]  J. Dudley,et al.  Engaging specialists in performance-incentive programs. , 2010, The New England journal of medicine.

[17]  D. Hoaglin,et al.  Enhancement of claims data to improve risk adjustment of hospital mortality. , 2007, JAMA.

[18]  Alain C Enthoven,et al.  Paying for performance: Medicare should lead. , 2003, Health affairs.

[19]  Bing Li,et al.  Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases , 2008, BMC health services research.

[20]  Sheila Roman,et al.  Public reporting and pay for performance in hospital quality improvement. , 2007, The New England journal of medicine.

[21]  A. Ryan Effects of the Premier Hospital Quality Incentive Demonstration on Medicare patient mortality and cost. , 2009, Health services research.

[22]  A. Jha,et al.  The Effect of Financial Incentives on Hospitals That Serve Poor Patients , 2010, Annals of Internal Medicine.