Intended and Unintended Consequences of Nonpayment for Preventable Complications

描述（由申请人提供）：财务激励措施，如按绩效付费（P4P）计划，越来越多地用于改善医生的行为。然而，这些计划对提高患者护理质量的影响好坏参半，一些研究显示出适度的收益，另一些研究报告称护理质量措施几乎没有改善。此外，P4P计划的意外后果已经得到证明，包括对那些在基线上表现更好的医院的更大的经济奖励，以及为大量少数民族人口服务的医院的重大经济损失。自2008年10月1日起，医疗保险实施了一种新的财务机制--可预防并发症不付款（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（HAI）的费用，这些感染发生在患者入院时不在场的情况下。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，NPPC是由美国最大的支付者之一实施的，尽管缺乏证据证明其有效性，但人们希望财政抑制措施将激励医院和供应商集中精力减少HAI。虽然目标当然是有价值的，但应严格评估用于推动变革的机制，以确保它实现预期的结果，而不会出现意外的后果。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Medicare报告的HAI率的影响（即“计费”费率）;（2）评估NPPC对NHSN报告的HAI费率的影响（即“真实”感染率）;（3）探讨NPPC是否降低了不同类型医院的“账单”和“真实”感染率（例如，营利与非营利）;以及（4）评估由于NPPC而减少的HAI报销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.