The faint correlation between the two programs underscores the limits of the current quality measures, which have been central to the intensifying federal effort to reduce healthcare waste and errors and slow U.S. spending on medical care, experts say.
“The science isn't quite there yet” to identify which organizational processes will deliver desired outcomes such as lower readmission rates, said Dr. Rachel Werner, an associate professor of medicine at the University of Pennsylvania.
While researchers are working to collect data on readmission-reduction strategies, she said, measures have not yet been developed for programs that better coordinate medications, doctors' visits and medical care in settings outside the hospital. The CMS, meanwhile, has finalized plans to include more outcomes-based measures, such as risk-adjusted mortality, in future iterations of its pay-for-performance program.
The CMS announced its first round of rewards and penalties for value-based purchasing, or VBP, in December. It scored hospitals based on their performance on clinical processes such as how quickly a heart attack patient receives an angioplasty or whether a heart failure patient receives discharge instructions. The final VBP score, which raised or reduced Medicare reimbursements by as much as 1%, also included a composite measure of patient experience.
The readmissions reduction program, whose first round of penalties of up to 1% were announced last fall, penalizes hospitals with higher-than-expected numbers of quickly returning patients. Patients who return to the hospital within 30 days of a discharge are widely considered a flag for lapses in care that may have caused their return. Federal penalties are set to steadily increase in coming years for excess readmissions, which are anathema to patients, hospitals and policymakers.
The Modern Healthcare analysis, which looked at the nearly 3,000 hospitals that were graded by both Medicare quality programs, found only a weak likelihood that hospitals would do well in both.
The weak correlation can be illustrated by the fact that hospitals that would be expected to earn penalties in both programs if the measures were closely linked did not. More than 40% of hospitals that faced the maximum 1% penalty for readmissions earned bonuses for value-based purchasing scores on patient-satisfaction and process-of-care measures, a Modern Healthcare analysis of CMS data shows.
Meanwhile, a similar percentage of hospitals that did not face penalties for excess readmissions nonetheless paid penalties for performance on value-based purchasing measures. And among hospitals that earned some penalties on readmissions, the results were more evenly split for value-based purchasing bonuses and penalties.
Data used in the Modern Healthcare analysis does have some limits. The population varies somewhat between Medicare's two incentive programs. Only the performance measures are weighted for hospital size. And the two incentive programs draw data from different time periods to calculate performance.
One likely reason for the weak correlation between the two programs is that the 12 clinical process measures used by Medicare's VBP program do not capture everything hospitals do to promote high quality and prevent repeated hospital visits, some experts say.
“There is limited evidence about the effective treatment and strategies for most acute-care conditions,” said Dr. Mihaela Stefan, an assistant professor of medicine at Tufts University.
She recently led a study team that analyzed hospital scores on more than two dozen process-of-care quality measures and readmission rates for patients older than 65. The results, published in the Journal of General Internal Medicine in October, found hospitals with better marks for process-of-care measures did not see lower rates of readmissions than hospitals with worse marks. Still, Stefan said reporting process measures should continue despite the weak correlation with readmissions, since process-of-care measures are among a limited number of quality measures with some evidence to show they do benefit patients.
Not everyone agrees.
Dr. Ashish Jha, an associate professor of health policy and management at the Harvard School of Public Health, said early efforts to measure quality correctly reported on processes of care. But the more valid measure now is actual outcomes, which is of most concern to patients. “It's time to move on,” Jha said.