Department of Health Services Management, Rush University, Chicago, IL, United States.
Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, United States.
Front Public Health. 2020 Jun 9;8:165. doi: 10.3389/fpubh.2020.00165. eCollection 2020.
With the passage of the Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act in 2010, Medicare's Inpatient Prospective Payment System (IPPS) began a transition to value-based purchasing (VBP) that rewards or penalizes hospitals based on patient satisfaction, clinical processes of care, outcomes, and efficiency metrics. However, hospital-level volatility vs. persistence in value-based payments year-over-year could result in unpredictable cash flows that negatively influence investment behavior, drive underinvestment in community benefit/population health management initiatives, and make management of the factors that drive the VBP adjustment more challenging. To evaluate the volatility and persistence of hospital VBP adjustments, the sample includes VBP adjustments and the associated domain scores for the 2,547 hospitals that participated in the program from 2013 to 2016. The sample includes urban (74%), teaching (29.1%), system affiliated (46.5%), and not-for-profit (63.6%) facilities. Volatility was measured using basic descriptive statistics, relative risk ratios, and a fixed effect, autoregressive, dynamic panel model that robust-clustered the standard errors. There is substantial change in a given facility's total VBP score with an average standard deviation of 10.74 (on a 100-point scale) that is driven by significant volatility in all metrics but particularly by efficiency and outcomes metrics. Relative risk ratios have dropped substantially over the life of the program, and there is low persistence of VBP scores from one period to the next. Findings indicate that if hospitals receive a positive adjustment in 1 year, they are almost as likely to receive a negative adjustment as a positive adjustment the following year. Furthermore, using a fixed-effect dynamic panel model that controls for autocorrelation, we find that only 13.5% of a facility's prior year IPPS adjustment (positive or negative) carries forward to the next year. The low persistence makes investment in population health management and community benefit more challenging.
随着 2005 年《减少赤字法案》和 2010 年《患者保护与平价医疗法案》的通过，医疗保险的住院患者前瞻性支付系统（IPPS）开始向基于价值的采购（VBP）过渡，根据患者满意度、护理临床流程、结果和效率指标对医院进行奖励或惩罚。然而，医院层面的 VBP 支付的波动性与逐年的持续性可能导致不可预测的现金流，从而对投资行为产生负面影响，抑制社区效益/人口健康管理计划的投资，使管理推动 VBP 调整的因素变得更具挑战性。为了评估医院 VBP 调整的波动性和持续性，该样本包括 2013 年至 2016 年参与该计划的 2547 家医院的 VBP 调整和相关领域评分。样本包括城市（74%）、教学（29.1%）、系统附属（46.5%）和非营利（63.6%）设施。波动性使用基本描述性统计、相对风险比以及固定效应、自回归、动态面板模型进行衡量，该模型对标准误差进行了稳健聚类。在给定设施的总 VBP 评分中，有相当大的变化，平均标准偏差为 10.74（在 100 分制上），这是由所有指标的显著波动性驱动的，但特别是由效率和结果指标驱动的。相对风险比在计划实施过程中大幅下降，VBP 评分从一个时期到下一个时期的持续性很低。研究结果表明，如果医院在一年内获得正向调整，那么它们在下一年获得负向调整的可能性几乎与正向调整相同。此外，我们使用固定效应动态面板模型控制自相关，发现只有 13.5%的设施前一年的 IPPS 调整（正负）会延续到下一年。低持续性使得投资于人口健康管理和社区效益更具挑战性。
