After reading Andrew Ryan’s perspective article on value-based purchasing (VBP) in the New England Journal of Medicine, I have to note that there are points to keep in mind before concluding that value-based purchasing puts disproportionate share (DSH) hospitals at a disadvantage.
However, I do agree with the assessment that VBP introduces potential for unintended consequences, and needs to be monitored to avoid disparities.
First, experience with VBP is still very early. The data for fiscal year 2013 payments were collected from a baseline period of July 1, 2009 to March 31 2010, and a performance period of July 1, 2011 to March 31, 2012. The early baseline was set just as hospitals were becoming accustomed to VBP, and few had instituted changes necessary to achieve the goals.
Second, during the Premier/CMS Hospital Quality Incentive Demonstration that established the model for VBP, high DSH hospitals performed at lower levels initially, but improved at a rapid pace.
In fact, high DSH hospitals performed comparably to low DSH peers within 4 years¹.
Finally, this paper shows variability that is by no means simple. In a number of cases, high DSH hospitals outperform those in the lower DSH grouping. Understanding these “positive outliers” is an important next step.
In our work with Premier hospitals in an improvement collaborative called QUEST, we undertook a qualitative investigation of rapidly improving hospitals using a realist evaluation framework:
Context * Intervention = Outcome²
Using this framework, we found high-performing hospitals shared several characteristics:
- A culture of improvement
- Visible involvement of senior leadership
- An emphasis on accountability
DSH status was not found to be a relevant factor.
Before advocating for policy changes based upon the limited experience of VBP, it might be more productive to understand why some DSH hospitals are able to outperform their non-DSH peers.
NOTES
¹ Kroch E, Lloyd D and Belk K, “Does P4P discriminate Against Hospitals that Serve Vulnerable Populations.” Long-term Impact Session of the AcademyHealth. 2010 Annual Research Meeting, Boston , MA, June 29, 2010.
² Bankowitz R, Butts-Dion S, Federico F, Kabcenell A, Nelson E, et. al. “Understanding Context-specific Variation in the Effectiveness of QUEST.” AcademyHealth 2012 Annual Research Meeting, Orlando, FL, June 24-26, 2012.