Access to Coronary Artery Bypass Graft Surgery Under Pay for Performance: Evidence From the Premier Hospital Quality Incentive Demonstration

Study Questions:

Does a policy of incentive-based, hospital pay for performance (P4P) encourage avoidance of high-risk surgical patients due to concerns of financial penalties?

Methods:

Little empiric data exist regarding the likelihood of P4P to decrease use of high-risk (but potentially beneficial) procedures like coronary artery bypass grafting (CABG). Using Medicare data, these investigators compared change in CABG rates between 2002 to 2003 and 2008 to 2009 among patients with acute myocardial infarction (AMI) admitted to 126 hospitals participating in Medicare’s Premier P4P program, with patients in 848 control hospitals. They examined rates for all AMI patients and those in the highest decile of predicted mortality. A total of 91,393 AMI patients admitted were identified at Premier hospitals and 502,536 AMI patients were at control hospitals. CABG rates for AMI patients at Premier hospitals decreased from 13.6% in 2002 to 2003 to 10.4% in 2008 to 2009; there was a comparable decrease in control hospitals (13.6%–10.6%; p value, 0.67). CABG rates for high-risk AMI patients at Premier hospitals decreased from 8.4% in 2002 to 2003, to 8.2% in 2008 to 2009; there was a similar decrease at control hospitals (8.4%–8.3%; p value, 0.82).

Results:

A total of 91,393 AMI patients admitted were identified at Premier hospitals and 502,536 AMI patients were at control hospitals. CABG rates for AMI patients at Premier hospitals decreased from 13.6% in 2002 to 2003 to 10.4% in 2008 to 2009; there was a comparable decrease in control hospitals (13.6%–10.6%; p value, 0.67). CABG rates for high-risk AMI patients at Premier hospitals decreased from 8.4% in 2002 to 2003 to 8.2% in 2008 to 2009; there was a similar decrease at control hospitals (8.4%–8.3%; p value, 0.82).

Conclusions:

The authors concluded that there is “no evidence of a deleterious effect of P4P” on access to CABG in AMI patients, including those at highest-risk.

Perspective:

This analysis by Epstein and colleagues provides some reassurances that P4P programs may not lead to avoidance of high-risk surgical patients due to concerns of financial penalties. P4P is well-known to American cardiologists. It is one of the major mechanisms by which payers and policy-makers are seeking to reform the fee-for-service payment system. P4P programs also will only grow in coming years through the large Medicare Value-Based Purchasing (VBP) program (built into the Affordable Care Act) and private insurance programs that closely mimic it. Although a rigorously performed analysis, there are some caveats to this study that deserve mention. First, it only deals with the Premier program—a program that has been criticized for ‘modest’ incentives that may not have influenced provider behavior as much as hoped. Yet, Premier remains the model for the larger Medicare VBP program, and thus, these results have implications for that program. Second, the analysis had to rely on claims data for risk-adjustment, which also means that appropriateness of CABG rates after AMI could not be ascertained (especially relative to medical therapy or percutaneous coronary intervention). Despite these limitations, this study is important and should comfort policy-makers hoping to use P4P programs to push our healthcare system even further toward the concept of increased ‘value.’

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Myocardial Infarction, Value-Based Purchasing, Research Personnel, Medicare, Coronary Artery Bypass, Patient Protection and Affordable Care Act, Percutaneous Coronary Intervention


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