Evidence showing that hospitals achieving high marks in cardiac care will not be rewarded in value-based care programs is mounting, In fact, such facilities may be penalized. The risk-adjustment models that determine payment under value-based systems do not adequately account for factors like patient mix. The result can be that hospital leaders feel like they are being punished for providing quality care. That may tempt some to game the system.

In recent research led by Rishi Wadhera, MD, cardiologist at Beth Israel Deaconess Medical Center and Harvard Medical School, a higher proportion of hospitals with superior cardiac care were financially penalized under the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based Purchasing Program (HVBPP) compared with other hospitals.

“Our study highlights the frustration that leaders at hospitals and healthcare systems are experiencing as they roll out initiatives to improve quality of care but are getting discordant messaging from multiple organizations about how they are performing,” Wadhera says. “We looked at what hospitals can control: the care they deliver within their walls. An ongoing controversy about federal value-based programs is that they really focus on measuring outcomes. But an outcome like readmissions is heavily affected by what happens outside the hospital walls.”

Hospitals awarded for high-quality cardiovascular care by the American Heart Association (AHA) and American College of Cardiology (ACC) had either similar or slightly lower 30-day mortality rates than other hospitals, the study notes.

Researchers examined 3,175 hospitals participating in the HRRP and 2,781 hospitals participating in the HVBPP in fiscal year 2018. For the HRRP participants, a higher proportion of hospitals lauded by the AHA and ACC received financial penalties (85.5% vs. 78.7%).

With HVBPP hospitals, a higher proportion of the award hospitals also received penalties (51.7% vs. 41.4%). A smaller percentage of award-winning HVBPP hospitals received financial rewards under the program than others, only 48.4% for those cited for high-quality cardiac care vs. 58.6% of others.

The results suggest the healthcare community needs to standardize how quality cardiac care is measured and ensure that value-based programs not penalize the best performing facilities, Wadhera says.

In the meantime, hospitals need to keep doing what they do best: ensure patients receive the highest quality care, he says. Facilities should roll out quality improvement initiatives leaders think will improve outcomes for patients regardless of whether the current value-based structure will reward them.

“The evidence from these value-based programs suggest that they have not improved care, they probably disproportionately penalize our most resource-constrained hospitals, and they may be widening disparities in care,” Wadhera says. “The Centers for Medicare & Medicaid Services [CMS] needs to be more responsive to evidence showing that maybe their programs are not working and maybe they are not improving care. Maybe we need to make changes based on healthcare systems’ insight so that they are incentivizing the delivery of high-quality care.”

Wadhera says CMS seems to be hearing the message and is realizing the programs are not working as intended when they were implemented almost 10 years ago.

“Hospitals have tried hard to improve the quality of care they deliver, but when you are being penalized every year, and you recognize that it’s not because of the quality of care you’re delivering but because of factors beyond your control, that’s when you start to see some gaming of these measures,” Wadhera says. “For the Hospital Readmission Reduction Program, it’s very clear that the number of patients returning has not declined, even though the rates are going down. That’s because hospitals are putting those patients in observation status and treating them more intensely in emergency rooms rather than admitting them.”

Manipulating the statistics like that can produce meaningful differences in how a hospital appears to be performing in comparison to other facilities, Wadhera says. That can result in unfair comparisons and change who is penalized, he says. “The question becomes whether outcomes like readmissions adequately reflect quality of care,” Wadhera says. “The answer is probably not.”


  • Rishi Wadhera, MD, Cardiologist, Beth Israel Deaconess Medical Center, Harvard Medical School. Email: rwadhera@bidmc.harvard.edu.