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Dr. Ashish Jha: "Does ‘Pay for Performance’ Work?" 6.28.16

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Dr. Ashish Jha: "Does ‘Pay for Performance’ Work?" 6.28.16

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Dr. Ashish Jha's slides from the Center for Health Journalism webinar "Does ‘Pay for Performance’ Work?" 6.28.16

http://www.centerforhealthjournalism.org/content/does-pay-performance-work

Dr. Ashish Jha's slides from the Center for Health Journalism webinar "Does ‘Pay for Performance’ Work?" 6.28.16

http://www.centerforhealthjournalism.org/content/does-pay-performance-work

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Dr. Ashish Jha: "Does ‘Pay for Performance’ Work?" 6.28.16

  1. 1. + Aligning Incentives for Better Outcomes: State of Play Ashish K. Jha, MD, MPH 28 June 2016 @ashishkjha
  2. 2. + Why do we need pay for performance?
  3. 3. + Variations in AMI Mortality 0 100 200 300 400 500 600 700 800 900 1000 5% 10% 15% 20% 25% 30% 35% 40% 45% NumberofHospitals Risk-adjusted 30-day Mortality Rates
  4. 4. + Why is Pay for Performance attractive? Has tremendous face validity Works in other industries Aligns incentives for better care:  Allows providers to do well when doing good
  5. 5. + Incentives 1.0: What did we try? Premier P4P  Began 2003  Small dollars  Process measures
  6. 6. + Did it work?
  7. 7. + 13.3% 11.2% 13.2% 10.9% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Q12002 Q22002 Q32002 Q42002 Q12003 Q22003 Q32003 Q42003 Q12004 Q22004 Q32004 Q42004 Q12005 Q22005 Q32005 Q42005 Q12006 Q22006 Q32006 Q42006 Q12007 Q22007 Q32007 Q42007 Q12008 Q22008 Q32008 Q42008 Q12009 Q22009 Q32009 Q42009 Premier Non-Premier Onset of Pay-for-performance Premier HQID: Did It Work? Jha et al. NEJM 2012
  8. 8. + And the news is discouraging too…  Headlines over the past 5 years:  “Health Affairs article finds Medicare’s pay-for- performance did not spur quality improvement”  “New NEJM Report: Pay-for-performance…a bust”  “Paying doctors for quality doesn’t work”  “Medicare’s policy did not reduce infection rates”
  9. 9. + What is the ACA doing for P4P? A variety of new programs Value-based purchasing Hospital Readmissions Reduction Program Hospital-Acquired Condition Reduction Now: MACRA and MIPS
  10. 10. + Will this work any better?
  11. 11. + We have some evidence in
  12. 12. + ACA Reform #1: HRRP Up to 3% penalty for high readmission rate For a select group of conditions
  13. 13. + HRRP: Impact on readmission rates 21.5% 17.8% 15.3% 13.1% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 Targeted conditions Non-targeted conditions Source: Zuckerman et al., NEJM 2016 ACA
  14. 14. + Which hospitals are getting penalized? 6.3% 5.7% 15.1% 20.9% 23.4% 17.8% 16.0% 7.2% 21.0% 30.4% 37.1% 27.0% 0% 5% 10% 15% 20% 25% 30% 35% 40% Percentage Black Percentage Hispanic Divorced/never married Less than High School Diploma Lowest Quartile of Household Income Medicaid Enrollment Low readmission rate hospital High readmission rate hospital Barnett et al., JAMA IM 2015
  15. 15. + ACA Reform #2: VBP (aka P4P) Up to 2% of Medicare payments tied to: Broad set of quality measures:  Processes  Outcomes  Patient Experience  Efficiency
  16. 16. + Impact of VBP on Mortality Rate 12.8% 11.2% 11.1% 15.8% 14.3% 14.3% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% Q1 2008 Q2 Q3 Q4 Q1 2009 Q2 Q3 Q4 Q1 2010 Q2 Q3 Q4 Q1 2011 Q2 Q3 start Q4 Q1 2012 Q2 Q3 Q4 Q1 2013 Q2 Q3 Q4 VBP Hospitals Non-VBP Hospitals Onset of VBP Figueroa et al., BMJ 2016
  17. 17. + Impact of VBP on Patient Experience 64 69 71 50 55 60 65 70 75 80 85 90 95 100 2008 2009 2010 2011 2012 2013 2014 PercentofPatientsRatingtheirHospital'9&10' Pre-VBP Slope= +1.46% per year Post-VBP Slope= +0.55% per year Onset of VBP
  18. 18. + What have we learned? Incentives can move the needle  Simple measures  Narrowly focused They can have unintended consequences  We need to understand the tradeoffs Do they make care meaningfully better?  Jury remains out
  19. 19. + Let’s reframe  Old question: “Does pay-for-performance work?”  New question: “How do we get pay-for-performance to work?”
  20. 20. + Incentives 2.0: What might it look like? Bigger incentives? Target a small number of outcomes?  Especially over the longer run  Across a broader set of measures Structure it more simply Play into intrinsic motivations More nuanced approach to the safety net
  21. 21. + Thank you Email: ajha@hsph.harvard.edu Twitter: @ashishkjha

Hinweis der Redaktion

  • This is an example of the variations in outcomes for acute myocardial infarction for Medicare patients entering a hospital in 2010. There are hospitals where outcomes are four times worse than those in other hospitals.

    Similarly, for cancer care – we see large variations in cancer-related death rates across medical centers, across states, and across regions.

    While the data are less well defined, there is plenty of reason to believe that there are clinically meaningful variations in use of evidence-based chemotherapy regimens, approaches to cancer surgeries, and other types of effective cancer care across different local healthcare markets.
  • Given these variations – there is a broad consensus that care is clearly suboptimal. In some instances, there may be “overuse” of un-necessary treatments – but for many critical conditions, the problem of “under use” is far more prevalent and problematic. Patients often fail to get evidence-based treatments.

    This is why policymakers and private payers turned to P4P: it has tremendous face validity.

    The notion is simple: align the incentives for better care. In the old “fee-for-service” world (which is still dominant in cancer care), you got paid more to do more. Providers generally didn’t get paid more to do “better” (that is, to be more evidence based).

    It works in most industries: higher quality providers of services get to charge more, deliver better services

    While P4P has been around for a very long time, it has gotten substantial traction in healthcare over the past 10 years
  • So have the efforts with P4P gone? These headlines tell the tale.
    Even as of August, 2014, in the NEJM – the latest disappointing story on P4P from England on hospital care – it didn’t work.
  • If you synthesize the broader field of P4P and its impact: the evidence is underwhelming. It doesn’t appear to work.
  • See sheet 1 in attached Excel file. Numbers are fudged a bit from Arnie’s paper, but starting and final rates are exact.

    Targeted conditions include: AMI, CHF, PNA (excluded hip/knee and COPD)

  • Data for odds ratios are found in Sheet 8 of the “Data for UCSF talk” excel file.
  • Sheet 2 in accompanying data file.
  • From Irini’s unpublished HCAHPS trends paper.

    Sheet 1 in accompanying data file.
  • The conversation on P4P has changed. It is no longer – does P4P work in healthcare? Because the alternatives are not palatable:

    Alternative #1 – status quo – not sustainable
    Alternative #2 – purely shift risk-taking to providers (i.e. bundled payments, capitation) without substantial quality targets. While this is more viable (and where we are heading) in the short run, lack of P4P and lack of robust quality targets will create substantial political and clinical problems with such models.

    Therefore, the real question we need to ask ourselves is: what do we need to do to get P4P to work?

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