Demonstration project continues gains in year two
Demonstration project continues gains in year two
Year three is looking even better
The Premier Hospital Quality Improvement Demonstration (HQID) project, a joint effort between Premier Inc., of Charlotte, NC, and the Centers for Medicare & Medicaid Services, continues to go from strength to strength.
The recently released second-year results of the hospital value-based purchasing demonstration project show an average improvement of 6.7% in the second year, leading to total gains of 11.8% for both years. Thus, the improvement rate in the second year actually topped that of the first year.
And things continue to get better. "We're seeing [the steady improvement] continued in the third year," says Stephanie Alexander, MBA, senior vice president of Premier. "It's not slowing down; I think it will be the same or better in year three."
The improvements resulted in incentive payments totaling about $8.7 million to 115 top-performing hospitals, according to CMS.
A breakdown of the numbers shows impressive gains in specific measures. "A good example is that in the first quarter of the project we were at 89.88% in the acute myocardial infarction [AMI] clinical focus group, and at the last quarter of the second year we were at 95.77%," reports Alexander. "For coronary artery bypass graft it went from 85.14% to 97.01%, and pneumonia went from 70% to 86.3%."
Hospitals participating in the Premier project submit data to Premier for validation and analysis. Premier then submits the data to CMS. The hospitals report process and outcome measures in five clinical areas — AMI, heart failure, coronary artery bypass graft, pneumonia, and hip and knee replacement.
There are financial incentives for the top 20% of high-scoring hospitals in each of the five clinical areas. The top 10% of all hospitals receive a 2% incentive payment for patients in that clinical area. Hospitals in the second decile receive a 1% incentive payment. Hospitals in the top 50% of each clinical area also are recognized on the CMS web site.
Examining the numbers
This steady improvement becomes more impressive when weighed against the knowledge that as a facility improves, each additional percentage of improvement becomes that much more difficult. Alexander notes, however, that there were some mitigating circumstances in year one.
"In the first year there was a lot going on; some people may call it 'noise,'" she notes. "Hospitals had to get prepared and get their infrastructure up and running, and as you can imagine, they were now documenting. In the second year, all that infrastructure was set and the hospitals could really focus on what matters."
Nevertheless, she adds, the numbers do tell a valuable story, "We took a subset of these measures [Hospital Compare, a publicly available web site established by CMS and the Hospital Quality Alliance], which are reported every quarter with a 12-month rolling average. When we compared the hospitals, every quarter we were getting better."
The entire nation is improving, she adds, but the 250 demonstration project participants were getting better at a statistically significant higher rate. "I would have thought that because the rest of the country [started] at a lower rate they'd be improving at a faster rate," she observes.
Why was this conventional wisdom turned on its ear? "I believe this is a combination of P4P and transparency; knowledge transfer is the silver bullet here," Alexander asserts.
Keeping the numbers high?
Just how difficult is it to maintain top-level performance? "I think it is difficult, because the nature of performance activities in health care is that if you take your eye off the ball you tend to deteriorate," says Charles Riccobono, MD, chief quality officer and chairman of the performance improvement department, Hackensack University Medical Center in New Jersey.
He should know: His facility, which provides care for 2,853 Medicare patients, was a top performer in all five areas for the second year in a row. The facility's total award across the five clinical areas will be about $744,000. "The key to our success is that we have used what we've learned about reliability science — a method of designing and building processes in such a way that they will be self-sustaining," says Riccobono. "But still, you have to continuously monitor and tweak your processes. You can get surprised; specific measures may change and you won't know why. You'll have to look at it, and you still may have to redesign your process."
Still, he says, the reliability approach (which he and his team try to build into everything they do) "has been very helpful in creating a process that is good from the beginning, and gets even better as we tweak it." Instead of a Band-Aid approach, he says, "We try to design process right from the beginning, then use things like [Failure Mode Effects Analysis] tools to predict how we might fail and try to prevent it. We look at process very seriously."
Riccobono adds that he and his team are learning along with many others. "We've worked on the Institute of Health Care Improvement's IMPACT project, where people shared a lot of information," he notes. "That's another great thing that has come out of this project — transparency, and hospitals communicating with each other."
Gap is closing
Another trend identified by Premier is that the range of variance among participating hospitals is closing, as those hospitals in the lower quality range continue to improve their quality scores and close the gap between themselves and the demonstration's top performers.
"We anticipated that in each year the variation would be reduced, and in fact in year two that has played out," says Alexander. "Premier's goal is to leave no one behind."
Premier was sufficiently pleased that it has formally announced a three-year extension of the project. (The project, launched in October 2003, originally was designed to be terminated after three years.) In actuality, year-three data have already been collected, but has not yet been reviewed and finalized by CMS.
And what of the future for P4P? "Last October, CMS did increase the financial risk of publicly reported data," notes Alexander, "but what they are working toward for this summer is to present to Congress their value-based purchasing plan, which they have been tasked to implement in 2009. They have prepared an issues paper and accepted written comments, and I believe a draft will be ready in April."
Riccobono says the incentive structure in the demonstration project will need to be amended going forward. "They will have to modify it because everybody is stacked at the top so tightly that with a small variance you plummet deciles," he notes. "I'm not sure that would be a sustainable process of incentivizing health care workers."
He also notes that while the positive numbers look good, they focus more on process than on outcomes. "[Premier] has probably done a lot more of looking at things from a global perspective than we have," he concedes. "We are waiting to see what happens. It's clear everyone is improving; people are taking these things seriously and pay attention to improving processes, which we hope results in better outcomes."
That, however, is "a little up in the air," Riccobono asserts. "Some of the data would make you think it's related, but some other data do not necessarily support that," he says. "But you can see that people are taking evidence-based practice seriously, and implementing them by improving their processes and delivery of care."
The bottom line, he says, is that "it's not so about making money as it is the interest of people in improving their care and [the public's] perception of their care."
For complete information about the HQID project and to view a list of those hospitals ranking in the top 50% in each focus area, visit www.cms.hhs.gov or contact:
Stephanie Alexander, MBA, Senior Vice President, Premier Inc., Charlotte, NC. Phone: (704) 733-5446.
Charles Riccobono, MD, Chief Quality Officer and Chairman, performance improvement department, Hackensack University Medical Center, Hackensack, NJ. Phone: (201) 996-2882.
The Premier Hospital Quality Improvement Demonstration (HQID) project, a joint effort between Premier Inc., of Charlotte, NC, and the Centers for Medicare & Medicaid Services, continues to go from strength to strength.Subscribe Now for Access
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