Many programs–such as Medicare’s Hospital Value-Based Purchasing (HVBP) program–aim to reward hospitals with high quality through higher reimbursement and penalize hospitals with low quality through lower reimbursement. Will this approach be successful?
A commentary by McMahon and Howell (2017) says that hospitals are not really unified entities but rather a collection of workshops.
Thus, the authors claim:
A policy that applies penalties across the entire Medicare line of business in a hospital based on the outcomes of selected tracer conditions is problematic. The hospital providers caring for patients with an acute myocardial infarction are different from those caring for patients with pneumonia: the doctors are different, the nurses are different, the social workers are different, the physical locations in the hospital are different. Penalizing the entire hospital for deficiencies in a specific type of disease neither makes sense nor is it likely to be an effective way of changing behavior.
So if value-based payments at the hospital level won’t work, what makes sense? The authors argue for better alignment between hospital and physician value-based purchasing programs.
Some physicians base the bulk of their practice and payment on hospital-centric services (for example, cardiac surgery); while others, like psychiatry, are less linked between inpatient processes and subsequent patient outcomes. For these hospital-centric product lines, the hospital-based penalties and quality metrics must necessarily be aligned with the physician-based penalties and quality metrics
More importantly, they argue that a better understanding of the key decision-makers, culture, and organization of hospitals is a necessary condition to affect any key quality improvements.
An interesting perspective and worth a read.
McMahon, Laurence F., and Joel D. Howell. “The Hospital: Still the Doctors’ Workplace (s)—A Cautionary Note for Approaches to Safety and Value Improvement.” Health Services Research (2017).