Responses to Medicare's Nonpayment for Preventable Hospital Complications

2008年10月1日，联邦医疗保险实施了一项政策，拒绝为8人提供增量支付 医疗护理中可预防的并发症。即使这项CMS政策涉及的范围有限 情况下，医院的反应可能会很大，因为许多人认为这一政策变化是 一系列CMS支付改革旨在加强对基于价值的采购的重视，使用两者 积极的激励和消极的惩罚。医院的反应可能比他们应该做的更重要 如果规则的变化是一个孤立的事件，而不是未来变化的先兆。此外，负面的 与同等的正面奖励相比，不偿还的“大棒”可能是更强大的动机，部分原因是 这不仅是因为收入损失，也是因为对一个组织造成的负面污名。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，这八项规则中的四项与 CMS确定为可预防的情况：导管相关尿路感染率，中心线- 相关的血流感染率、跌倒和医院获得性压疮。我们还将评估如何 医院的反应可能会根据具体情况而有所不同，例如财务状况和市场状况 条件。具体地说，我们建议解决以下研究问题：(1) CMS支付规则的改变对这四种情况的发生？(2)医院情况会如何 是否会影响对CMS支付规则更改的响应？以及(3)医院如何改变其质量 针对CMS支付规则更改的改进活动(QI)？ 国家护理质量指标数据库(NDNQI)数据与美国医院合并 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将 用于使用多层次、中断的时间序列检查医院对CMS支付变化的响应 单位、医院和市场特征影响患者结局的模式。六家医院拥有不同的 还将选择结果改进的级别进行深入的现场访问，重点是 由于CMS支付政策而发生的质量改进活动以及障碍 和促进者来改变。因为负面激励的相对新颖性，以及 规则变化向医院发送有关未来医疗保险支付变化的信息，我们的研究将提供重要信息 向全国各地的政策制定者和支付者介绍这些政策达到预期的程度 结果。我们还将提供重要信息，说明如何根据具体情况做出不同的回应 医院状况，如财务状况和市场状况。财务状况不佳的医院可能 在新的支付规则下损失更大，增加了他们在支持质量改进活动方面的问题。 在这个动荡的金融时期，旨在提高医疗质量的支付激励措施起到关键作用 不会因其造成的财务压力而产生影响质量的意外影响。

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 be 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.