A new study published on May 9, 2016, in the British Medical Journal (BMJ) has found that Hospital Value Based Purchasing (HVBP) program has not influenced the performance of hospitals in terms of better outcomes or lowered mortality rates, specifically the 30-day mortality rate.

The trends of risk adjusted mortality rates in any of the hospitals, with or without the program, all pointed to the same result: they were worse than before.

The researchers could not find better outcomes in any of the hospitals which implemented the HVBP program, nor  in any subset hospitals with worst patient mortality at baseline,   which arguably had more reasons to improve and avoid penalties.

The trends in mortality for better disease or patient outcomes also slowed down for the hospitals not implementing the program.

Hospital Value Based Purchasing (HVBP) program, introduced in 2011 as a national policy in United States, incentivizes the healthcare facilities (hospitals) to improve their performance in terms of clinical outcomes such as patient outcomes, patient experience, cost efficiency, 30-day mortality rates for pneumonia, heart failure and myocardial infarction. The 30-day mortality rate indicates death within thirty days of a hospital admission.

The program can also penalize the hospitals on the basis of these same indicators mentioned above.

The program introduced by the Centers for Medicare and Medicaid Services (CMS), under the guise of Affordable Care Act of 2010 or ObamaCare, and in a bid to improve and provide the public with better healthcare services, is based on a budget neutral design. Medicare holds back a percentage of the payments made to the hospital and redistributes it according to the performance.

According to the official CMS site, the program accounts for the largest share of Medicare spending, which influences payment for inpatient stays in nearly 3500 hospitals in the country.

In 2015, Medicare redistributed money by awarding bonus payments to 1,700 hospitals and penalizing 1,360 other facilities.

The latest study is significant for analyzing the performance of the program, possibly leading to modifications in the  program, or for even helping in exploring other ventures to improve hospital care system in United States. The study can also further help with international healthcare services’ policy design or in improving hospital quality of care in other countries using this particular model or another.

The observational study was conducted by the researchers at Harvard University, by the Department of Medicine at Brigham and Women’s Hospital Boston, as well as VA Boston healthcare system. The study used data from 4,267 acute care facilities; 1,348 as controls which did not take part in the program and 2,919 as the study group which participated in the HVBP program.

A total of 2,43,0618 participants’ data was analyzed, who were admitted in the hospitals from 2008 to 2013. The data was completely extracted from official Medicare inpatient claims.

The study focused on two key areas of performance in association with patient outcomes: namely, the 30-day risk adjusted mortality for heart failure, acute myocardial infarction, and pneumonia and the performance of the hospitals at the baseline (with previous poor results) after the adoption of the said program. The non-incentivized medical conditions were used as comparators in the study.

The results indicated that the mortality rates of the incentivized hospitals participating in the program declined at a rate of — 0.13% and -0.03% in each quarter, during pre- intervention and post — intervention period.

For hospitals, assumed as controls in the study, the mortality rates declined at the point difference of -0.14% and -0.01% for each quarter during pre-intervention and post-intervention period.

With no significant difference in the mortality trends of the two groups, at -0.03 difference in point differences in each quarter, and no better outcomes seen in poor performance hospitals at the baseline, the researchers concluded the program to be ineffective in  helping improve  the hospital services.

The researchers received no grant or financial support to carry out this research and disclosed no conflict of interests.

Policy recommendations included looking for ‘better mix of quality metrics and incentives to improve patient outcomes’ along with alternative models to improve the healthcare services.

Previously, the US Premier Hospital Quality Incentive Demonstration (HQID) program, on which the HVBP was based, also failed to improve patient outcomes.

According to a previous Harvard study, the demonstration launched in 2003 was initiated to determine whether financial and economic incentives could help hospitals to improve their quality of patient care. With 250 participants involved across 36 US states in the form of teaching, non-teaching, small, large, rural and urban hospitals, the rates of 30-day mortality seen were the same for premier and non-premier hospitals.

The study therefore forecasted modest results for the programs modeled after the Premier HQID.