dr. ashish jha: "does ‘pay for performance’ work?" 6.28.16
TRANSCRIPT
+
Aligning Incentives for Better Outcomes:
State of Play
Ashish K. Jha, MD, MPH
28 June 2016@ashishkjha
+ Why do we need pay for
performance?
+Variations in AMI Mortality
0
100
200
300
400
500
600
700
800
900
1000
5% 10% 15% 20% 25% 30% 35% 40% 45%
Nu
mb
er
of
Ho
sp
itals
Risk-adjusted 30-day Mortality Rates
+Why is Pay for Performance attractive?
Has tremendous face validity
Works in other industries
Aligns incentives for better care:
Allows providers to do well when doing good
+Incentives 1.0: What did we try?
Premier P4P
Began 2003
Small dollars
Process measures
+
Did it work?
+
13.3%11.2%
13.2%
10.9%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Q1
20
02
Q2
20
02
Q3
20
02
Q4
20
02
Q1 2
003
Q2
20
03
Q3
20
03
Q4
20
03
Q1
20
04
Q2 2
004
Q3
20
04
Q4
20
04
Q1
20
05
Q2
20
05
Q3
20
05
Q4
20
05
Q1
20
06
Q2
20
06
Q3
20
06
Q4
20
06
Q1
20
07
Q2
20
07
Q3
20
07
Q4
20
07
Q1
20
08
Q2
20
08
Q3
20
08
Q4
20
08
Q1
20
09
Q2
20
09
Q3
20
09
Q4
20
09
Premier Non-Premier
Onset of Pay-for-performance
Premier HQID: Did It Work?
Jha et al. NEJM 2012
+And the news is discouraging too…
Headlines over the past 5 years:
“Health Affairs article finds Medicare’s pay-for-
performance did not spur quality improvement”
“New NEJM Report: Pay-for-performance…a bust”
“Paying doctors for quality doesn’t work”
“Medicare’s policy did not reduce infection rates”
+What is the ACA doing for P4P?
A variety of new programs
Value-based purchasing
Hospital Readmissions Reduction Program
Hospital-Acquired Condition Reduction
Now: MACRA and MIPS
+ Will this work any better?
+ We have some evidence in
+ACA Reform #1: HRRP
Up to 3% penalty for high readmission rate
For a select group of conditions
+HRRP: Impact on readmission rates
21.5%
17.8%15.3%
13.1%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2007 2008 2009 2010 2011 2012 2013 2014 2015
Targeted conditions
Non-targeted conditions
Source: Zuckerman et al., NEJM 2016
ACA
+Which hospitals are getting penalized?
6.3% 5.7%
15.1%
20.9%
23.4%
17.8%16.0%
7.2%
21.0%
30.4%
37.1%
27.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Percentage Black PercentageHispanic
Divorced/nevermarried
Less than HighSchool Diploma
Lowest Quartileof Household
Income
MedicaidEnrollment
Low readmission rate hospital High readmission rate hospital
Barnett et al., JAMA IM 2015
+ACA Reform #2: VBP (aka P4P)
Up to 2% of Medicare payments tied to:
Broad set of quality measures:
Processes
Outcomes
Patient Experience
Efficiency
+Impact of VBP on Mortality Rate
12.8%11.2%
11.1%
15.8%14.3% 14.3%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Q12008
Q2 Q3 Q4 Q12009
Q2 Q3 Q4 Q12010
Q2 Q3 Q4 Q12011
Q2 Q3start
Q4 Q12012
Q2 Q3 Q4 Q12013
Q2 Q3 Q4
VBP Hospitals Non-VBP Hospitals
Onset of VBP
Figueroa et al., BMJ 2016
+Impact of VBP on Patient Experience
64
69
71
50
55
60
65
70
75
80
85
90
95
100
2008 2009 2010 2011 2012 2013 2014
Pe
rce
nt
of
Pa
tie
nts
Ra
tin
g t
he
ir H
os
pit
al '9
& 1
0'
Pre-VBP Slope=
+1.46% per year
Post-VBP Slope=
+0.55% per year
Onset of VBP
+What have we learned?
Incentives can move the needle
Simple measures
Narrowly focused
They can have unintended consequences
We need to understand the tradeoffs
Do they make care meaningfully better?
Jury remains out
+Let’s reframe
Old question: “Does pay-for-performance work?”
New question: “How do we get pay-for-performance to
work?”
+Incentives 2.0: What might it look like?
Bigger incentives?
Target a small number of outcomes?
Especially over the longer run
Across a broader set of measures
Structure it more simply
Play into intrinsic motivations
More nuanced approach to the safety net
