Magnet Hospitals and 30-Day Readmission and Mortality Rates for Medicare Beneficiaries.

BACKGROUND: US hospitals are penalized for excess 30-day readmissions and mortality for select conditions. Under the Centers for Medicare and Medicaid Services policy, readmission prevention is incentivized to a greater extent than mortality reduction. A strategy to potentially improve hospital performance on either measure is by improving nursing care, as nurses provide the largest amount of direct patient care. However, little is known as to whether achieving nursing excellence, such as Magnet status, is associated with improved hospital performance on readmissions and mortality. OBJECTIVE: The purpose of this study was to examine the relationship between hospitals' Magnet status and performance on readmission and mortality rates for Medicare beneficiaries. RESEARCH DESIGN: This is a cross-sectional analysis of Medicare readmissions and mortality reduction programs from 2013 to 2016. A propensity score-matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. SUBJECTS: The sample was comprised of 3877 hospitals. MEASURES: The outcome measures were 30-day risk-standardized readmission and mortality rates. RESULTS: Following propensity score matching on hospital characteristics, we found that Magnet hospitals outperformed non-Magnet hospitals in reducing mortality; however, Magnet hospitals performed worse in reducing readmissions for acute myocardial infarction, coronary artery bypass grafting, and stroke. CONCLUSIONS: Magnet hospitals performed better on the Hospital Value-Based Purchasing Mortality Program than the Hospital Readmissions Reduction Program. The results of this study suggest the need for The Magnet Recognition Program to examine the role of nurses in postdischarge activities as a component of its evaluation criteria.

Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review.

BACKGROUND: Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE: To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN: We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS: Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.

Do Magnet®-Designated Hospitals Perform Better on Medicare's Value-Based Purchasing Program?

OBJECTIVE: The aim of this study was to explore the relationship between a hospital's Magnet recognition status, tenure, and its performance in the Hospital Value-Based Purchasing (HVBP) program. BACKGROUND: Previous studies have sought to determine associations between quality of care provided in inpatient setting and the Magnet Recognition Program; however, no study has done so using the most recent (FY2017) iteration of the HVBP program, nor determined the influence a hospital's Magnet designation tenure has on HVBP scores. METHOD: This study used a cross-sectional study design of 2686 hospitals using propensity score matching to reduce bias and improve comparability. RESULTS: Magnet-designated hospitals were associated with higher total performance, process of care and patient experience of care scores, and lower efficiency score. No association was identified between the length of time hospitals have been Magnet designated. CONCLUSION: Findings suggest non-Magnet status hospitals need to consider implementing the principles of Magnet into their culture or participation in the Magnet Recognition Program to provide higher quality of care.

Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives.

BACKGROUND: The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider. METHODS: Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors. RESULTS: A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all). CONCLUSION: This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.

Hospital Value-Based Purchasing Performance: Do Organizational and Market Characteristics Matter?

EXECUTIVE SUMMARY: The hospital value-based purchasing (HVBP) program of the Centers for Medicare & Medicaid Services challenges hospitals to deliver high-quality care or face a reduction in Medicare payments. How do different organizational structures and market characteristics enable or inhibit successful transition to this new model of value-based care? To address that question, this study employs an institutional theory lens to test whether certain organizational structures and market characteristics mediate hospitals' ability to perform across HVBP domains.Data from the 2014 American Hospital Association Annual Survey Database, Area Health Resource File, the Medicare Hospital Compare Database, and the association between external environment and hospital performance are assessed through multiple regression analysis. Results indicate that hospitals that belong to a system are more likely than independent hospitals to score highly on the domains associated with the HVBP incentive arrangement. However, varying and sometimes counterintuitive market influences bring different dimensions to the HVBP program. A hospital's ability to score well in this new value arrangement may be heavily based on the organization's ability to learn from others, implement change, and apply the appropriate amount of control in various markets.

Current State of Value-Based Purchasing Programs.

The US healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, solidified the role of value-based payment in Medicare. Many private insurers are following Medicare's lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in Medicare Access and CHIP Reauthorization Act and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated; the impact of those programs has been marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care.

Elements of Program Design in Medicare's Value-based and Alternative Payment Models: a Narrative Review.

Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context. We found that current Medicare payment models vary significantly across each parameter of program design examined. For example, in terms of scope, the HRRP focuses exclusively on risk-standardized excess readmissions and the HACRP on patient safety. In contrast, HVBP includes 21 measures in five domains, including both quality and cost measures. Choices regarding penalties versus bonuses are similarly variable: HRRP and HACRP are penalty-only; HVBP, VM, and MIPS are penalty-or-bonus; and the MSSP and MA quality star rating programs are largely bonus-only. Each choice has distinct pros and cons that impact program efficacy. Unfortunately, there are scant data to inform which program design choice is best. While no one approach is clearly superior to another, the variability contained within these programs provides an important opportunity for Medicare and others to learn from these undertakings and to use that knowledge to inform future policymaking.

Creating incentives to move upstream: developing a diversified portfolio of population health measures within payment and health care reform.

I examined the feasibility of developing a balanced portfolio of population health measures that would be useful within the current deliberations about health care and payment reform. My commentary acknowledges that an obstacle to the selection of population health metrics is the differing definitions of population health. Rather than choosing between these definitions, I identified five categories of indicators, ranging from traditional clinical care prevention interventions to those that measure investment in community-level nonclinical services, that in various combinations might yield the most promising results. I offer concrete examples of markers in each of the categories and show that there is a growing number of individuals eager to receive concrete recommendations and implement population health pilot programs.

The Relationship Between Hospital Value-Based Purchasing Program Scores and Hospital Bond Ratings.

Tax-exempt hospitals and health systems often borrow long-term debt to fund capital investments. Lenders use bond ratings as a standard metric to assess whether to lend funds to a hospital. Credit rating agencies have historically relied on financial performance measures and a hospital's ability to service debt obligations to determine bond ratings. With the growth in pay-for-performance-based reimbursement models, rating agencies are expanding their hospital bond rating criteria to include hospital utilization and value-based purchasing (VBP) measures. In this study, we evaluated the relationship between the Hospital VBP domains--Clinical Process of Care, Patient Experience of Care, Outcome, and Medicare Spending per Beneficiary (MSPB)--and hospital bond ratings. Given the historical focus on financial performance, we hypothesized that hospital bond ratings are not associated with any of the Hospital VBP domains. This was a retrospective, cross-sectional study of all hospitals that were rated by Moody's for fiscal year 2012 and participated in the Centers for Medicare & Medicaid Services' VBP program as of January 2014 (N = 285). Of the 285 hospitals in the study, 15% had been assigned a bond rating of Aa, and 46% had been assigned an A rating. Using a binary logistic regression model, we found an association between MSPB only and bond ratings, after controlling for other VBP and financial performance scores; however, MSPB did not improve the overall predictive accuracy of the model. Inclusion of VBP scores in the methodology used to determine hospital bond ratings is likely to affect hospital bond ratings in the near term.

Improving the patient experience: real-world strategies for engaging nurses.

Patients spend more time with nurses during an admission than with any other profession in the hospital. Nurses and their interactions with patients are central to shaping and improving the patient's experience. Patient experience, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, drives 30% of value-based purchasing (VBP) scores and incentive payments, as prescribed under the Patient Protection and Affordable Care Act. Hospital performance on the communication with nurses' domain within HCAHPS predicts performance on several other domains. In addition, nurses at the bedside have significantly lower engagement scores than nurses who are not involved in direct patient care. Considering the relationship between nurse engagement and patient experience and the relationship between patient experience and hospital success under VBP, pursuing strategies and tactics that will foster and sustain nurse engagement is critical for nurse executives.

Hospital value-based purchasing (VBP) program: measurement of quality and enforcement of quality improvement.

VBP program is a novel medicare payment estimatin tool used to encourage clinical care quality improvement as well as improvement of patient experience as a customer of a health care system. The program utilizes well established tools of measuring clinical care quality and patient satisfaction such as the hospital IQR program and HCAHPS survey to estimate Medicare payments and encourage hospitals to continuosly improve the level of care they provide.

Look ahead to succeed under VBP.

The Centers for Medicare & Medicaid Services (CMS) is adding new metrics to its Value-based Purchasing Program each year, and case managers should look ahead to ensure that their hospital performs well on the measures. CMS automatically withholds a percentage of the Medicare base operating payment each year (1.5% in fiscal 2015), and hospitals can earn back what was deducted or more by performing well. Value-based purchasing for 2015 includes four domains: clinical processes of care, outcomes, Hospital Consumer Assessment of Healthcare Programs and Systems (HCAHPS), and hospital efficiency of care. Any measure that is in the Inpatient Quality Reporting Program is considered to be on deck for value-based purchasing.

Discharge planning takes spotlight as VBP focuses on efficiency.

Hospital efficiency of care, a new domain in the Centers for Medicare & Medicaid Services Value-based Purchasing Program, bases hospital scores on spending three days before admission through 30 days after discharge. Case managers need to take the time to develop a discharge plan that works and look at cost-effectiveness as well as appropriateness of the level of care, experts say. Because the data used for this measure is risk-adjusted, it's crucial for the documentation in the medical record to clearly and accurately reflect the patient's severity of illness. Become familiar with all the potential discharge destinations and spend time with each provider, experts recommend.

CMS emphasizes quality patient care.

The Inpatient Prospective Payment System proposed rule for fiscal 2015 continues the Centers for Medicare & Medicaid Services' move toward basing reimbursement on quality of care, not quantity. The rule also asks for public input on the two-midnight rule and a policy to address short-stay patients. CMS is implementing the Hospital-Acquired Condition Reduction Program, which penalizes hospitals that perform poorly. The agency proposes to add two safety measures to value-based purchasing in the future.

Surgical care improvement project in the value-based purchasing era: more harm than good?

The Surgical Care Improvement Project (SCIP) started in 2006 as a core measure to reduce perioperative morbidity and mortality, with many measures addressing perioperative antibiotic usage and timing. However, measures are often rolled out without consideration of their full impact, causing confusion, frustration, and possibly patient harm. We have provided examples of each. The institution of SCIP has markedly increased the compliance to its measures but little evidence shows that it provides any substantial benefit to patients, whereas this improved compliance comes at the cost of significant time, money, and staff resources. Despite this, several SCIP measures, which are currently incorporated into quality contracts, will be tied to Medicare reimbursement in 2013 under value-based purchasing, with third-party payers likely following suit. This may lead to inappropriate lower compensation of hospitals providing good care with questionable effects on patient outcomes.

An early look at performance on the emergency care measures included in Medicare's hospital inpatient Value-Based Purchasing Program.

STUDY OBJECTIVE: Medicare's new, mandatory Hospital Inpatient Value-Based Purchasing Program introduces financial rewards or penalties to hospitals according to achievement or improvement on several publicly reported quality measures. Our objective was to describe hospital reporting on the 4 emergency department (ED)-related program measures, variation in performance on the ED measures across hospital characteristics, and the characteristics of hospitals that were more likely to receive performance scores based on improvement versus achievement. METHODS: This was an exploratory, descriptive analysis. We merged 2008 to 2010 performance data from Hospital Compare with the 2009 American Hospital Association Annual Survey. We calculated a composite score for the 4 ED measures and used Kruskal-Wallis tests to examine differences in performance across hospital characteristics. We also examined differences in the percentage of scores that were awarded according to improvement versus achievement. RESULTS: There were 2,927 hospitals that qualified for the value-based purchasing program and were included in the analysis. For-profit hospitals received the highest scores; public hospitals and hospitals lacking The Joint Commission (TJC) accreditation received the lowest scores. Public hospitals had the largest share of scores awarded according to improvement (39.8%); for-profit hospitals had the lowest (27.8%). CONCLUSION: We found variation in performance by hospital characteristics on the ED-related program measures. Although public and non-TJC-accredited hospitals trailed in performance, they showed strong signs of improvement, signaling that performance gaps by ownership and accreditation may decrease. Considering the increasing scope of the value-based purchasing program, ED leaders should monitor both achievement and improvement on the 4 ED-related program measures.

Diabetes: the right care and the right reimbursement.

Managing patients with diabetes or other chronic diseases is suddenly a major focus for hospitals. They're working with insurers to develop fair, effective reimbursement models.

The VALUE Framework: training residents to provide value-based care for their patients.

National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care.