The long-term effect of premier pay for performance on patient outcomes

摘要

Tying financial incentives to performance, a pay-for-performance strategy, is now a widely accepted method to improve the quality of health care. The Centers for Medicare and Medicaid Services/Premier Hospital Quality Incentive Demonstration (HQID) was a 6-year study of pay for performance in US hospitals. Although the data from the Premier HQID provided evidence that pay for performance is associated with modest improvements in health care, it remains unclear whether tying financial incentives to performance will result in better patient outcomes.The present study investigated the long-term effect of the Premier HQID on patient outcomes. Medicare data were used to compare medical and surgical outcomes between 252 hospitals participating in the Premier HQID and 3363 non-Premier hospitals (controls) participating in public reporting alone. The investigators examined 30-day mortality among more than 6 million patients who were treated between 2003 and 2009 for acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary artery bypass grafting (CABG).There was no significant difference at baseline in the composite 30-day mortality between Premier and non-Premier hospitals [12.33% and 12.40%, respectively; the difference was -0.07 percentage points, with a 95% confidence interval (CI) of -0.40 to 0.26]. The decline in mortality rates was similar at Premier and non-Premier hospitals (-0.04% and -0.04% per quarter, respectively (difference: -0.01 percentage points per quarter; 95% CI, -0.02 to 0.01; P = 0.55). After 6 years, no significant difference in overall mortality across these 4 conditions occurred in Premier and the non-Premier hospitals (11.8% and 11.7%, respectively; the difference was 0.1 percentage points, with a 95% CI of -0.3 to 0.5). With pay for performance, no significant difference in mortality was found among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia; P = 0.36 for interaction). Overall mortality among hospitals that were poor performers at baseline was similar at Premier and non-Premier hospitals (15.1% and 14.7%; difference, 0.4 percentage points; 95% CI, -0.4 to 1.2), with no difference in the rate of improvement over time (-0.10% vs -0.07% per quarter, respectively; difference, -0.03 percentage points; 95% CI, -0.08 to 0.02; P = 0.22). Similarly, at the end of the study period, there was no difference in overall mortality between the 2 groups of hospitals (13.4% vs 13.2%; difference, 0.2 percentage points; 95% CI, -0.7 to 1.0).These findings provide no evidence that the hospital-based pay-for-performance program led to lower 30-day mortality rates. Congress has mandated that Center for Medicaid and Medicare Services adopt pay for performance for hospitals. These and other data show that expectations for programs modeled after Premier HQID should be modest.