Intended and Unintended Consequences of Nonpayment for Preventable Complications

描述（由申请人提供）：经济激励措施，例如按绩效付费（P4P）计划，越来越多地用于改善医生行为。然而，这些计划对提高患者护理质量的影响参差不齐，一些研究显示效果有限，而另一些研究则报告护理质量措施几乎没有改善。此外，P4P 计划的意外后果也已被证明，包括对基线绩效较高的医院给予更大的经济奖励，以及为大量少数族裔人口服务的医院造成重大经济损失。从2008年10月1日起，Medicare实施了新的财务机制——可预防并发症不付费（NPPC）——这是一根“大棒”而不是“胡萝卜”。如果患者入院时不在场，医疗保险将不再向医院支付治疗某些医疗相关感染 (HAI) 的费用。我们提出的研究是独特且及时的。目前还没有对 NPPC 的影响进行评估，该计划由美国最大的支付者之一实施。尽管缺乏证据证明其有效性，但希望财务抑制措施将激励医院和医疗服务提供者集中精力减少医院感染。虽然目标当然是有价值的，但应该严格评估用于激励变革的机制，以确保其实现预期结果，而不会发生意外后果。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 Medicare 使用 NPPC 对向 Medicare 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（即“计费”率）的影响； (2) 评估 NPPC 对 NHSN 报告的 HAI 率（即“真实”感染率）的影响； (3) 探讨 NPPC 是否降低了不同类型医院（例如营利性医院与非营利性医院）的“计费”和“真实”感染率； (4) 评估因 NPPC 导致 HAI 报销减少是否会对照顾大量贫困或少数族裔患者的医院产生不成比例的影响。

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.