Policy Points: Incentive for Quality
(cont.)
New York’s approach
Reporting data to the public about the
quality of health-care providers is not just a federal
function. State governments and private organizations also have
been involved. In the 1990s, the New York State Department of
Health became the first state to report on the outcomes of
coronary artery bypass surgery and angioplasties. The state
reports mortality rates for hospitals and individual doctors on
a risk-adjusted basis.
The number of deaths
associated with each provider is noted along with risk-adjusted
mortality rates. The state says, “The risk-adjusted
mortality rate represents the best estimate, based on the
associated statistical model, of what the provider’s
mortality rate would have been if the provider had a mix of
patients identical to the statewide mix.”
Factors used in determining
risk include the age of the patient, hemodynamic state,
ejection fraction, and comorbidities, such as cerebrovascular
disease, peripheral vascular disease, and renal failure.
Asterisks after the entries for individual hospitals and
doctors indicate whether the risk-adjusted mortality rates for
a provider are significantly lower or higher than the statewide
rates. The Department of Health’s reports are available
on line at www.health.state.ny.us/statistics/
Between 1989 and 2002,
the state’s mortality rate from bypass surgery dropped by
36 percent—from an annual rate of 3.53 percent to an
annual rate of 2.27 percent. It is not known the degree to
which the drop in mortality rate can be attributed specifically
to the data-reporting system versus general improvements in
quality of care not connected to the data-reporting system.
Nonetheless, the data reporting system is believed to have
influenced certain practices, including having more experienced
surgeons operate on high-risk patients and making more efforts
to stabilize patients before surgery.
A coalition of New York
employers and insurance companies tracks mortality rates for a
variety of procedures and conditions, including hip
replacement, craniotomy, acute stroke, and pneumonia. This data
is available on line from the Niagara Health Quality Coalition
at www.myhealthfinder.com under “Hospital Quality” and “Health Care Quality
Reports.”
Pay for performance
In addition to making consumers more
informed, Medicare has begun a demonstration project to make
higher payments to hospitals for improved performance. In May,
Mark B. McClellan, MD, PhD, the administrator of CMS, announced
the result of the first year of a three-year demonstration
project.
Two hundred seventy
hospitals participated in the project, and, as a group, the
hospitals increased their quality scores by between 3 percent
and 12 percent. Five areas were measured: heart attack,
coronary artery bypass surgery, heart failure, hip and knee
replacement, and pneumonia. The performance measures were the
same seventeen measures posted on the Hospital Compare Web
site, plus seventeen other measures.
If a hospital in the
demonstration project scores in the top 10 percent for a given
condition, it will receive a 2 percent bonus in Medicare
payments for that condition. If a hospital scored in the second
10 percent, it will receive a 1 percent bonus. Hospitals in the
remainder of the top 50 percent receive recognition for quality
care, but no bonus. In future years of the demonstration
project, baselines will be established for performance, and if
a hospital does not score above the baseline, it will have its
reimbursement rates cut by 1 or 2 percent. CMS anticipates
providing bonuses totaling $21 million over a three-year
period.
CMS said that “By
achieving improvements in aspects of care that are proven to
help patients avoid complications, patients are less likely to
require more costly follow-up care for such conditions, and
they are more likely to have a better quality of life.”
g
Jeff Atkinson teaches courses in
health-care law and policy at DePaul University College of Law
in Chicago, where he graduated summa cum laude. He writes on
legal, medical, and ethical issues.
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