The effect of pay-for-performance in nursing homes: evidence from state Medicaid programs.
The effect of pay-for-performance in nursing homes: evidence from state Medicaid programs.
复制标题
疗养院按绩效付费的影响：来自州医疗补助计划的证据。
DOI：
10.1111/1475-6773.12035
复制
发表时间：
2013
影响因子：
3.4
通讯作者：
Polsky,Daniel
中科院分区：
文献类型：
--
作者：
Werner,RachelM;Konetzka,RTamara;Polsky,Daniel
在美国，绩效薪酬（P4P）通常用于提高医疗质量，预计将在《平价医疗法案》（Affordable care Act）下频繁实施。然而，支持其使用的证据是混合的，很少有大规模的，严格的P4P评估。本研究测试了大规模设置P4P对护理质量的影响-由国家医疗补助机构实施的养老院P4P。数据来源/研究设置2001 - 2009年养老院最小数据集和在线调查、认证和报告（OSCAR）数据集。研究设计2001年至2009年间，八个州医疗补助机构在养老院采用了P4P计划。我们采用差异中差异的方法来测试P4P下养老院质量的变化，利用这8个州实施时间的变化，并使用42个非P4P州和华盛顿特区的养老院作为同期对照。P4P下的质量改善不一致。虽然有P4P的州与没有P4P的州相比，有P4P的州实施P4P后，有三个临床质量指标（身体受限、中度至重度疼痛和出现压疮的居民比例）有所改善，但其他有针对性的质量指标要么没有改变，要么恶化。在与支付挂钩的两项质量结构性措施（缺陷总数和护士人员配备）中，在P4P下，缺乏率略有恶化，而人员配备水平没有变化。结论：基于医疗补助的养老院P4P并没有导致养老院质量的持续改善。对P4P下养老院护理改善的期望应该有所缓和。
ObjectivePay‐for‐performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large‐scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large‐scale setting—the implementation of P4P for nursing homes by state Medicaid agencies.Data Sources/Study Setting2001–2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting (OSCAR) datasets.Study DesignBetween 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference‐in‐differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non‐P4P states plus Washington, DC as contemporaneous controls.Principal FindingsQuality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change.ConclusionsMedicaid‐based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered.