What's next for value-based purchasing metrics, hospital transparency, and quality scoring? Hospitals, get ready.
By now, you're getting used to the idea that public scoring and pay-for-performance have arrived. The 33 process and outcome measures hospitals must perfect to earn up to 2% of their Medicare DRG payments – the first to take effect on July 1 – are set for the next two years.
Down the road, the Affordable Care Act says, 'The Secretary shall' select additional process or outcome measures to determine each facility's paychecks going forward. What likely endpoints will those be? What weak spots in their systems should providers be rushing to improve?
I put that question to Leah Binder, CEO of the 10-year-old Leapfrog Group, the nation's first healthcare performance coalition to evaluate and post hospital performance comparisons online. The coalition of 65 employers purchases healthcare for 34 million people, and now publishes data on 1,224 voluntarily participating hospitals with dozens of mortality and system quality metrics.
Surgical "survival predictors," will be key, Binder replies, without missing a beat. Leapfrog's website displays predictors of death during hospitalization for patients undergoing six high-risk surgical procedures for the last two years:
Only those hospitals with sufficient numbers of procedures are included. This isn't an old 30-day mortality statistic for conditions such as pneumonia, as in the 2014 VBP score. These numbers represent a patient's chance of future mortality.
The idea is to give healthcare purchasers a sense of their chances of having a bad outcome, and to give employers more information when they're deciding how to spend their health plan dollars.
Yes, giving discharge instructions, complying with antibiotic selection rules, and giving patients a positive experience – the metrics being rolled out by the Centers for Medicare & Medicaid Services this year —are important.
But the bottom line is what everyone really wants to know. What is the chance a patient might die during or after a pancreatic resection at hospital A versus hospital B? That's what's coming, Binder says.
"This is such powerful data," she says. "We're saying, 'this is your chance of survival if you go to this hospital and have this procedure. That's as raw edged as you can get in terms of transparency."
Take esophageal resection in Massachusetts: At Brigham and Women's Hospital, patients have a 3.29% odds of dying whereas at North Shore Medical Center Salem Hospital, it's 9.78%.
And for pancreatic resection in New Jersey: At John F. Kennedy Medical Center in Edison, patients have an 10.61%, chance of dying, compared with 3.85% at Morristown Memorial.
In fact, the variation among all the hospitals reporting resection survival scores is huge, she says. For esophageal resection over the last two years, the very best hospitals a patient has a 2.9% chance of mortality while at the worst hospitals, the odds are 12.1%. For pancreatic resection, no hospitals are in the best category, but the worst hospitals have death rates at 19% and 21%.
Expectedly, many hospitals aren't ready to volunteer this information. It's controversial, Binder acknowledges. It's embarrassing for some hospitals that don't do as well as their competitors. Hospital and physician groups have balked.
Despite rock-solid scientific evidence supporting the listing of these scores, the National Quality Forum has endorsed survival calculations for just three the six procedures: pancreatic resection, esophageal resection, and abdominal aortic aneurysm repair. So far they've declined to endorse the other three, but Binder thinks they will be eventually.
"There is no measure that has ever gone through the scrutiny and the scientific requirements that these measures went through in the NQF process," Binder told me.
Many more surgical procedures and other high-risk types of hospital procedures will get the same level of scrutiny.
As Binder travels the country speaking to many hospital leaders, she says she's struck by how many non-Leapfrog participants still have their heads in the proverbial sand about transparency, still refusing to release their data.
"A lot of them are hunkering down thinking they can hide this, at least until the value-based purchasing (scores) are made public. They aren't focused at all on this. And I think that couldn't be a worse strategy."
I asked why she thinks hospitals are reluctant. "They think transparency is a problem because so many measures 'can be misinterpreted' that kind of thing," she answers. "But my statement to them is that no measures are perfect. They need to be transparent because that's how they're going to survive."
"Transparency," she continues, "is how you build community support. You start to build bridges with other providers in the community that you need to be working with and that's how you build trust."
Binder says many employer groups are worried about accountable care organizations, because they fear "here's just another monopoly in the community that will give them fewer opportunities to contract; they'll just raise costs and employers won't know why. But hospital transparency is the way to break down suspicions."
Another thing hospital quality leaders should brace themselves for, Binder says, is precise percentage point scoring as opposed to the way Hospital Compare posts data today, which tells consumers and other providers very little. For example, she says about 95% of the hospitals show up as "average." And the remaining 5% as either good or bad.
"Value-based purchasing is just not going to work if you don't show variation because these cut offs don't show hospitals differentiating that much," Binder said. Don Berwick, MD, administrator for the Centers for Medicare & Medicaid Services, "has been absolutely clear," she added, that when hospital scores are posted for VBPP, they will make much finer distinctions.
Binder says that hospitals and other providers should "stay tuned, because there's a lot more to come."
"We use the best science out there to get information to the public, because people have a right to know: How am I going to do when I come to your hospital."