Responses to Medicare's Nonpayment for Preventable Hospital Complications

描述（由申请人提供）：2008年10月1日，联邦医疗保险实施了一项政策，拒绝对8种可预防的医疗并发症进行增量支付。尽管这一CMS政策在涉及的条件方面是有限的，但医院的反应可能是实质性的，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，旨在加强对基于价值的采购的重视，同时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，而不是未来变化的前兆，那么医院的反应可能会更加显著。此外，不报销的负面“棍棒”可能比同等的积极奖励更具激励作用，部分原因是收入损失，但也因为这给组织带来了负面的耻辱。我们建议检查医疗保险新的不付款规则对医院行为的影响，这些行为与CMS确定的可预防的八种情况中的四种有关：导尿管相关尿路感染率、中央静脉相关血流感染率、跌倒和医院获得性压疮。我们还将评估医院的反应如何因具体情况而异，例如财务状况和市场状况。具体而言，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何影响？(2)医院环境对医保支付规则变化的响应有何影响？(3)医院如何改变其质量改进活动（QI）以应对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医院年度调查数据、医疗保险成本报告和地区资源文件数据合并，将使用多层次、中断时间序列模型来检查医院对CMS支付变化的反应，其中单位、医院和市场特征影响患者的结果。还将选择结果改善程度不同的六家医院进行深入的实地考察，重点关注由于CMS支付政策而发生的质量改进活动的变化，以及改变的障碍和促进因素。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，我们的研究将为全国各地的政策制定者和支付者提供重要信息，了解此类政策在多大程度上实现了预期结果。我们还将提供重要信息，说明根据医院的具体情况（如财务状况和市场状况），应对措施可能会有何不同。在新的支付规则下，财务状况不佳的医院可能损失更多，使它们在支持质量改进活动方面的问题更加严重。在当前动荡的金融时代，至关重要的是，旨在提高医疗质量的支付激励措施不能因其造成的财政压力而产生意想不到的影响，从而损害医疗质量。

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.