Intended and Unintended Consequences of Nonpayment for Preventable Complications

描述（由申请人提供）：财务激励，如绩效薪酬（P4P）计划，越来越多地被用于改善医生的行为。然而，这些项目对提高患者护理质量的影响参差不齐，一些研究显示出适度的收益，而另一些研究则报告在护理质量方面几乎没有改善。此外，P4P项目的意想不到的后果已经被证明，包括那些在基线上表现较高的医院获得了更大的经济回报，而为大量少数民族人口服务的医院则遭受了重大的经济损失。自2008年10月1日起，联邦医疗保险实施了一种新的金融机制——不支付可预防并发症（NPPC）——这是一种“大棒”而不是“胡萝卜”。医疗保险不再支付医院治疗某些医疗保健相关感染（HAIs）的费用，这些感染发生在病人入院时没有出现的情况下。我们提出的研究是独特和及时的。目前还没有对NPPC的影响进行评估，美国最大的付款人之一正在实施NPPC，尽管缺乏其有效性的证据，但人们希望财政激励将激励医院和提供者集中精力减少HAIs。虽然目标肯定是值得的，但是用于激励变化的机制应该被严格地评估，以确保它达到预期的结果，而不会出现意想不到的结果。我们的研究旨在了解NPPC对健康结果和成本的积极和消极影响。我们将评估医疗保险使用NPPC对向医疗保险和国家医疗安全网络（NHSN）报告数据的医院的结果和成本的影响。我们的目标是：(1)评估NPPC对医疗保险报告的HAI率的影响。“账单”率);(2)评估NPPC对NHSN报告的HAI率的影响。“真实”感染率)；(3)探讨NPPC是否降低了不同类型医院（如营利性与非营利性）的“计费”和“真实”感染率；(4)评估NPPC导致的医疗保健机构报销减少是否不成比例地影响了照顾高比例贫困或少数民族患者的医院。

DESCRIPTION (provided by the applicant): Financial incentives, such as pay-for-performance (P4P) programs, are increasingly being used to improve physician behavior. However, the impacts of these programs on improving quality of care for patients have been mixed, with some studies showing modest gains and others reporting little to no improvement on quality of care measures. Furthermore, unintended consequences of P4P programs have been demonstrated, including larger financial rewards for those hospitals with higher performance at baseline and significant financial losses for hospitals that serve large minority populations. As of October 1, 2008, Medicare implemented the use of a new financial mechanism-nonpayment for preventable complications (NPPC)-which is a "stick" rather than a "carrot". Medicare no longer pays hospitals for treating certain healthcare-associated infections (HAIs) that arise in patients if they are not present on admission. Our proposed research is unique and timely. There are no evaluations of the impact of NPPC, which is being implemented by one of the largest payers in the U.S. Despite lack of evidence for its efficacy, it is hoped that financial disincentives will motivate hospitals and providers to focus their efforts on reducing HAIs. While the goal is certainly worthy, the mechanism being used to motivate change should be rigorously evaluated to ensure that it achieves its intended consequence without the occurrence of unintended consequences. Our research seeks to understand the impact, both positive and negative, of NPPC on health outcomes and costs. We will assess the impact of Medicare's use of NPPC on outcomes and costs in hospitals that report data to Medicare and the National Healthcare Safety Network (NHSN). Our aims are: (1) To evaluate the impact of NPPC on HAI rates reported by Medicare (i.e. "billing" rates); (2) To evaluate the impact of NPPC on HAI rates reported by NHSN (i.e. "true" infection rates); (3) To explore whether NPPC reduces both "billing" and "true" infection rates in different types of hospitals (e.g. for-profit vs. not-for-profit); and (4) To assess whether reduced reimbursement for HAIs as a result of NPPC disproportionately affects hospitals that care for a high proportion of poor or minority patients.