Responses to Medicare's Nonpayment for Preventable Hospital Complications

描述(申请人提供)：2008年10月1日，联邦医疗保险实施了一项政策，拒绝对八种可预防的医疗并发症进行递增支付。尽管这项CMS政策在涉及的条件方面有限，但医院的反应可能是巨大的，因为许多人认为这一政策变化是一系列CMS支付改革的第一步，旨在增加对基于价值的采购的重视，使用积极的激励和消极的惩罚。如果规则的改变是一个孤立的事件，而不是未来变化的先兆，医院的反应可能会比这更重要。此外，与同等的正面奖励相比，不报销的负面“大棒”可能是更强大的激励因素，部分原因是收入损失，但也因为给组织带来负面污名。我们建议检查联邦医疗保险新的拒付规则对医院行为的影响，这些规则与CMS确定为可预防的八种情况中的四种相关：导管相关尿路感染率、中心线相关血流感染率、跌倒和医院获得性压疮。我们亦会评估医院的反应会因应个别情况而有所不同，例如财政状况和市场情况。具体地说，我们建议解决以下研究问题：(1)CMS支付规则的变化对这四种情况的发生率有什么影响？(2)医院的情况将如何影响对CMS支付规则变化的反应？以及(3)医院如何改变其质量改进活动(QI)以响应CMS支付规则的变化？国家护理质量指标数据库(NDNQI)数据与美国医院协会年度医院调查数据、医疗保险成本报告和地区资源文件数据合并，将用于检查医院对CMS支付变化的反应，使用多水平、中断的时间序列模型，在该模型中，单位、医院和市场特征影响患者的结果。还将选择六家成果改善程度不同的医院进行深入实地访问，重点是合作医疗支付政策导致的质量改进活动的变化，以及需要变化的障碍和促进者。由于负面激励的相对新颖性，以及规则变化向医院发出的关于未来医疗保险支付变化的信号，我们的研究将向全国各地的政策制定者和支付者提供关键信息，说明此类政策在多大程度上实现了预期的结果。我们还将提供重要的信息，说明如何根据特定的医院情况，如财务状况和市场状况，做出不同的反应。在新的支付规则下，财务状况不佳的医院可能会损失更多，这增加了它们在支持质量改进活动方面的问题。在当前动荡的金融时期，至关重要的是，旨在提高医疗质量的支付激励措施不会因其造成的财政压力而产生影响质量的意外影响。 公共卫生相关性：我们建议检查医疗保险拒付规则对医院行为的影响，这些行为与CMS确定为可预防的八种情况中的四种相关：导管相关尿路感染率、中心线相关血流感染率、跌倒和医院获得性压疮。我们还将评估医院的反应如何根据特定情况而变化，以及哪些因素可能与有意义的变化或很少或没有变化相关。

DESCRIPTION (provided by applicant): On October 1, 2008, Medicare implemented a policy that denies incremental payment for eight preventable complications of medical care. Even though this CMS policy is limited in terms of involved conditions, hospital reaction may be substantial because this policy change is viewed by many as the first in a series of CMS payment reforms intended to increase its emphasis on value-based purchasing, using both positive incentives and negative penalties. Hospital responses are likely to be more significant than they would be if the rule change was an isolated event rather than a precursor of future change. In addition, the negative 'stick' of non-reimbursement may be a more powerful motivator than an equal positive reward, in part because of revenue loss but also because of the negative stigma that results for an organization. We propose to examine the impact of Medicare's new nonpayment rule on hospital behavior related to four of the eight conditions identified by CMS as preventable: catheter-associated urinary tract infection rates, central line- associated blood stream infection rates, falls, and hospital-acquired pressure ulcers. We will also assess how hospital responses may vary depending on particular circumstances, such as financial health and market conditions. Specifically, we propose to address the following research questions: (1) What is the impact of the CMS payment rule change on the incidence of these four conditions? (2) How will hospital circumstances influence responses to the CMS payment rule changes? And (3) How have hospitals altered their quality improvement activities (QI) in response to the CMS payment rule changes? National Database of Nursing Quality Indicators (NDNQI) data merged with American Hospital Association Annual Survey of Hospitals data, Medicare Cost Reports, and Area Resource File data will be used to examine hospital responses to the CMS payment change using multi-level, interrupted time series models in which unit, hospital and market characteristics influence patient outcomes. Six hospitals with varying levels of outcomes improvement will also be selected for in-depth site visits, focusing on the changes in quality improvement activities that have occurred as a result of the CMS payment policy, as well as the barriers and facilitators to change. Because of the relative novelty of negative incentives, as well as the signal that the rule change sends to hospitals about future Medicare payment changes, our study will provide vital information to policymakers and payers across the country about the extent to which such policies achieve intended results. We will also provide important information on how responses may vary depending on particular hospital circumstances, such as financial health and market conditions. Hospitals in poor financial health may lose more under the new payment rules, adding to their problems in supporting quality improvement activities. In these turbulent financial times, it is critical that payment incentives designed to improve quality of care do not have unintended effects that compromise quality due to the financial pressure they create. PUBLIC HEALTH RELEVANCE: We propose to examine the impact of Medicare's nonpayment rule on hospital behavior related to four of the eight conditions identified by CMS as preventable: catheter-associated urinary tract infection rates, central line-associated blood stream infection rates, falls, and hospital-acquired pressure ulcers. We will also assess how hospital responses may vary depending on particular circumstances and what factors may be associated with meaningful versus little or no change.