The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.

BACKGROUND: Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical. PURPOSE: The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. METHODOLOGY/APPROACH: A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade. RESULTS: We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains. CONCLUSION: Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics. PRACTICE IMPLICATIONS: Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

Value-Based Payment and Vanishing Small Independent Practices.

This Viewpoint explores the shift from fee-for-service to value-based payment models and the resulting trend of physician employment moving away from independent practices toward corporate health institutions.

Towards Efficient Value-Based Healthcare Measurement Across Hospital Care Pathways - A Scoping Review.

Hospitals widely employ value-based healthcare (VBHC) to effectively manage healthcare quality. VBHC aims to maximize patient outcomes while minimizing costs by using quality measurements. The Dutch Erasmus Medical Centre experiences challenges with the time-consuming efforts to collect, evaluate, and present value-based quality measurements. Using similar VBHC measurement indicators across multiple care pathways could reduce these efforts. This study aims to identify such generic indicators for evaluating and monitoring VBHC across care pathways. A scoping review resulted in 33 articles from which indicators for VBHC measurement were extracted, aggregated and categorized using Donabedian's Structure-Process-Outcome model. The results of this study can inform researchers and VBHC practitioners on generic quality measurement indicators for VBHC management and guide future system development to facilitate the inclusion of standardized quality indicators in healthcare information systems.

Value-Based Contracting in Clinical Care.

This cohort study analyzes quality incentives, requirements, and other measures in employment and payer contracts of primary care clinicians.

Understanding the Perspectives of Key Stakeholders toward Medicare's Home Health Value-Based Purchasing (HHVBP) in the US.

OBJECTIVES: This study examines the perspectives of key stakeholders in home health toward Medicare's Home Health Value Based Purchasing (HHVBP) program, piloted among home health agencies (HHAs) in 9 states from 2016 to 2021, and based on initial performance, was expanded to the remaining 41 (nonpilot) states in January 2023. DESIGN: We conducted semistructured interviews wherein we inquired participants' views toward and experiences with HHVBP. We used convenience and purposive sampling to obtain diversity in HHA size, geography, and quality. SETTING AND PARTICIPANTS: We conducted interviews from July 2022 to May 2023 with HHA leaders, staff, and clinicians, advocacy and trade organization leaders, and policy experts from pilot and nonpilot states. METHODS: We used thematic analysis to develop a codebook that included framework-derived, a priori, and inductive codes. We identified key themes and subthemes accordingly. RESULTS: Forty-seven stakeholders representing 25 unique organizations participated: 22 (47%) from pilot states and 25 (53%) from nonpilot states; of these, 24 (51%) were HHA leaders, 13 (28%) were organizational leaders, and 10 (21%) were clinicians; 26 (55%) were centered in the Northeast, 9 (19%) in the West, 7 (15%) had a national presence, and 5 (11%) were centered across the South. Four key themes emerged. There were (1) wide variations in awareness, understanding, and attitudes toward HHVBP regardless of pilot status or stakeholder type; (2) concerns about aspects of HHVBP, including consequences for HHAs and patients; (3) a range of strategies used by HHAs to address HHVBP; (4) other concurrent issues that HHAs were navigating alongside HHVBP. CONCLUSIONS AND IMPLICATIONS: Despite HHVBP's national implementation, awareness of and attitudes toward HHVBP varied across stakeholders from pilot and nonpilot states, as did efforts to address it. Although some viewed the policy favorably, others were concerned it could negatively impact HHAs and patients. Understanding the experiences of stakeholders is vital for illuminating the intended and unintended consequences of HHVBP policy.

Cheaper is not always better: Drug shortages in the United States and a value-based solution to alleviate them.

Drug shortages threaten patients' access to medications and are associated with adverse health outcomes and increased costs. Drug shortages disproportionately occur among generic drugs of limited profitability, most notably drugs administered by injection. In this perspective, we discuss how reimbursement and purchasing practices that were meant to create an efficient marketplace for generics have generated strong price pressure that threatens profitability in certain markets. We further explain how, faced with limited profitability, manufacturers lack incentives to invest in resilient supply chains, and in some cases, engage in cost-containment strategies or decide to exit the market, ultimately contributing to shortages. We propose the development and implementation of value-based reimbursement to provide needed incentives for drug purchasers and manufacturers to establish a more reliable supply chain as part of the policy solution to reduce the number and extent of drug shortages. This reimbursement model would necessitate the development of a rating system that measures supply chain resilience and maturity for each generic product. This rating would then be applied as a value-based modifier to reimbursement rates for generic products. The proposed model would result in higher reimbursement rates for generic products from more dependable supply chains, generating incentives for manufacturers to invest in supply chain resiliency. We propose the application of this reimbursement system originally in Medicare given Congressional interest on reforming Medicare payment to prevent drug shortages.

Preparing for Value: Evaluating Organizational Culture in Health Care Transformation.

The health care industry is experiencing a transformative shift from traditional fee-for-service models to value-based care (VBC), emphasizing improved patient outcomes, enhanced quality, and reduced costs. While Centers for Medicare & Medicaid Services Innovation Center models focus on financial and quality outcomes, a critical opportunity for reform lies in organizational culture. VBC signifies a cultural and systemic evolution aligned with the quintuple aim of enhancing equitable patient outcomes, improving quality, reducing costs, and prioritizing provider well-being. Cultural impacts play a pivotal role in this transformation.

Misaligned Pharmacy Incentives in Value-Based Care.

This Viewpoint explains some ways in which the alignment of incentives between payers and clinicians in value-based care (VBC) arrangements can be interrupted and proposes a multifaceted approach to realigning incentives for drug spending within VBC contracts to better provide value-based care and improve patient outcomes.

Patient satisfaction and value based purchasing in hospitals, Odisha, India.

Objective: To examine how a general inpatient satisfaction survey functions as a hospital performance measure. Methods: We conducted a mixed-methods pilot study of the Hospital Consumer Assessment of Health Providers and Systems survey in Odisha, India. We divided the study into three steps: cognitive testing of the survey, item testing with exploratory factor analysis and content validity indexing. Cognitive testing involved 50 participants discussing their interpretation of survey items. The survey was then administered to 507 inpatients across five public hospitals in Odisha, followed by exploratory factor analysis. Finally, we interviewed 15 individuals to evaluate the content validity of the survey items. Findings: Cognitive testing revealed that six out of 18 survey questions were not consistently understood within the Odisha inpatient setting, highlighting issues around responsibilities for care. Exploratory factor analysis identified a six-factor structure explaining 66.7% of the variance. Regression models showed that interpersonal care from doctors and nurses had the strongest association with overall satisfaction. An assessment of differential item functioning revealed that patients with a socially marginalized caste reported higher disrespectful care, though this did not translate into differences in reported satisfaction. Content validity indexing suggested that discordance between experiences of disrespectful care and satisfaction ratings might be due to low patient expectations. Conclusion: Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

The Promise and Challenge of Value-Based Payment.

This Viewpoint discusses the benefits and challenges of transitioning to a value-based payment design for health care rather than a fee-for-service system.

Trends in HCAHPS Survey Scores, 2008-2019: A Quality Improvement Perspective.

BACKGROUND: HCAHPS' 2008 initial public reporting, 2012 inclusion in the Hospital Value-Based Purchasing Program (HVBP), and 2015 inclusion in Hospital Star Ratings were intended to improve patient experiences. OBJECTIVES: Characterize pre-COVID-19 (2008-2019) trends in hospital consumer assessment of healthcare providers and systems (HCAHPS) scores. RESEARCH DESIGN: Describe HCAHPS score trends overall, by phase: (1) initial public reporting period (2008-2013), (2) first 2 years of HVBP (2013-2015), and (3) initial HCAHPS Star Ratings reporting (2015-2019); and by hospital characteristics (HCAHPS decile, ownership, size, teaching affiliation, and urban/rural). SUBJECTS: A total of 3909 HCAHPS-participating US hospitals. MEASURES: HCAHPS summary score (HCAHPS-SS) and 9 measures. RESULTS: The mean 2007-2019 HCAHPS-SS improvement in most-positive-category ("top-box") responses was +5.2 percentage points/pp across all hospitals (where differences of 5pp, 3pp, and 1pp are "large," "medium," and "small"). Improvement rate was largest in phase 1 (+0.8/pp/year vs. +0.2pp/year and +0.1pp/year for phases 2 and 3, respectively). Improvement was largest for Overall Rating of Hospital (+8.5pp), Discharge Information (+7.3pp), and Nurse Communication (+6.5pp), smallest for Doctor Communication (+0.8pp). Some measures improved notably through phases 2 and 3 (Nurse Communication, Staff Responsiveness, Overall Rating of Hospital), but others slowed or reversed in Phase 3 (Communication about Medicines, Quietness). Bottom-decile hospitals improved more than other hospitals for all measures. CONCLUSIONS: All HCAHPS measures improved rapidly 2008-2013, especially among low-performing (bottom-decile) hospitals, narrowing the range of performance and improving scores overall. This initial improvement may reflect widespread, general quality improvement (QI) efforts in lower-performing hospitals. Subsequent slower improvement following the introduction of HVBP and Star Ratings may have reflected targeted, resource-intensive QI in higher-performing hospitals.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program.

Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults.

The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.

Black Americans, hospitalization, and advance care planning: Structural vulnerability in Home Health Value-Based Purchasing.

Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman's correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.