Intended and Unintended Consequences of Nonpayment for Preventable Complications

描述(由申请人提供)：财政激励措施，如绩效工资(P4P)计划，正越来越多地被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是喜忧参半的，一些研究显示略有改善，另一些研究报告在护理质量措施方面几乎没有改善。此外，已经证明了P4P计划的意外后果，包括为那些在基线上表现更好的医院提供更大的经济奖励，以及为大量少数族裔人口服务的医院遭受重大经济损失。从2008年10月1日起，联邦医疗保险实施了一种新的财务机制--不为可预防的并发症支付费用(NPPC)--这是一根“大棒”，而不是“胡萝卜”。如果患者在入院时没有出现，联邦医疗保险不再为治疗某些与医疗保健相关的感染(HAI)而向医院付费。我们提出的研究是独一无二的，也是及时的。目前还没有对NPPC的影响进行评估，NPPC是由美国最大的付款人之一实施的。尽管缺乏其有效性的证据，但人们希望经济上的阻碍将激励医院和提供者将他们的努力集中在减少HAIs上。虽然这一目标肯定是值得的，但应严格评估用来推动变革的机制，以确保其实现预期结果而不发生意想不到的后果。我们的研究试图了解NPPC对健康结果和成本的积极和消极影响。我们将评估联邦医疗保险使用NPPC对向联邦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对医疗保险报告的HAI率(即“账单”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)探索NPPC是否同时降低了不同类型医院的“账单”和“真实”感染率(例如，营利性与非营利性)；以及(4)评估NPPC导致的医保报销减少是否会对照顾高比例贫困或少数族裔患者的医院造成不成比例的影响。

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.