医疗保险的医院绩效支付计划对质量和安全结果的综合影响喜忧参半。
Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.
机构信息
Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington, Avenue, KY, 40536, Lexington, USA.
Department of Statistics, University of Florida, 102 Griffin-Floyd Hall, PO Box 118545, 32611, Gainesville, FL, USA.
出版信息
BMC Health Serv Res. 2022 Jul 28;22(1):958. doi: 10.1186/s12913-022-08348-w.
BACKGROUND
Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus.
METHODS
We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients.
RESULTS
Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results.
CONCLUSIONS
Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.
背景
《平价医疗法案》引入了三项主要的医院按绩效付费（P4P）计划，旨在提高向医疗保险受益人提供的护理的质量、安全性和效率。医院与医疗保险的 P4P 计划相关的财务风险是巨大的。然而，这些计划的积极影响的证据一直存在争议，并且没有研究评估它们的综合影响。在这项研究中，我们研究了医疗保险的 P4P 计划对计划所针对的临床领域和人群以及计划之外的人群的综合影响。
方法
我们使用了 2007-2016 年 14 个州的医疗保健成本和利用项目州住院数据库，按季度和付款人（医疗保险与非医疗保险）确定医院级别的住院质量指标（IQI）和患者安全指标（PSI）。IQI 和 PSI 是标准化的、基于证据的措施，可用于使用医院管理数据随着时间的推移跟踪医院的护理质量和患者安全。选择 2007-2016 年的研究期是为了捕捉在计划指标引入之前和之后的多个年份。中断时间序列用于分析 P4P 计划对计划所针对和未针对的研究结果的影响。在敏感性分析中，我们研究了这些计划对非医疗保险患者护理的影响。
结果
医疗保险的 P4P 计划并未导致针对和非针对的质量和安全措施的一致改善。此外，在医疗保险的 P4P 计划推出后，针对和非针对条件的死亡率普遍恶化。PSI 的趋势极为混杂，五个结果朝着预期的（改善）方向发展，五个结果朝着意想不到的（恶化）方向发展，三个结果随着时间的推移没有明显变化。敏感性分析并没有实质性地改变这些结果。
结论
与之前针对个别计划的研究一致，我们发现医疗保险的医院 P4P 计划对质量和安全的影响很小，如果有的话。考虑到监测和执行处罚的行政成本以及潜在的死亡率增加，鉴于有限影响的证据不断增加，CMS 应该考虑在继续扩大这些计划之前重新设计它们的 P4P 计划。
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