Study highlights potential need to standardize quality measurement for cardiovascular care
In a new study published today in JAMA Cardiology, a team of researchers led by Rishi Wadhera, MD, MPP, MPhil, an investigator in the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center (BIDMC), found that hospitals that received awards from the American Heart Association (AHA) and American College of Cardiology (ACC) for the delivery of high-quality care for acute myocardial infarction (AMI) and heart failure (HF) were more likely to be financially penalized under value-based programs than other hospitals.
"Our findings highlight that evaluations of hospital quality for acute myocardial infarction and heart failure care differ between the American Heart Association/American College of Cardiology national quality improvement initiatives and federal value-based programs," said Wadhera. "Hospitals recognized by the AHA/ACC for high quality care were more likely to be financially penalized by federal value-based programs than other hospitals, despite achieving similar and/or better outcomes."
Since the passage of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) have implemented national value-based programs that aim to incentivize the delivery of higher value care. The Hospital Readmissions Reduction Program (HRRP) imposes financial penalties on hospitals with higher-than-expected 30-day readmission rates. In addition, the Hospital Value-Based Purchasing Program (VBP) - a pay-for-performance initiative—rewards or penalizes hospitals based on their performance on multiple domains of care, including 30-day mortality. Both programs have focused on heart failure and acute myocardial infarction, in part due to their clinical and financial burden.
In this study of hospitals that received awards for high quality cardiovascular care from AHA/ACC national quality improvement initiatives, the researchers observed several findings about those hospitals' performance in national value-based programs:
- Hospitals recognized for high quality care by the AHA/ACC ("award hospitals") were more likely to be penalized by the HRRP and VBP compared with other hospitals.
- Award hospitals were less likely to receive financial rewards (payment increases) by the VBP.
- Median payment reductions were higher for award hospitals than other hospitals under the VBP, and median payment increases were lower.
The team of researchers concluded that one potential explanation for the difference in evaluations of hospital quality may be that AHA/ACC award hospitals are disproportionately penalized by value-based programs for factors unrelated to the quality care they deliver. Award hospitals tended to be larger, urban, teaching hospitals—sites that often care for medically and socially complex populations. Because risk-adjustment models used for value-based programs do not include important clinical and social risk factors (e.g. poverty), award hospitals may be penalized for the patient populations and communities they serve rather than for poor quality of care.
"As the shift to value-based care continues in the United States and as multiple bodies simultaneously assess hospital systems, we need to prioritize efforts to promote fair, equitable and standardized measurement of cardiovascular care quality," said Wadhera, who is also an Instructor in Medicine at Harvard Medical School.