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Has pay-for-performance decreased access for minority patients?
1Department of Public Health, Weill Medical College-Cornell University, 402 East 67th Street, LA-215, New York, NY 10065, USA. amr2015@med.cornell.edu
Insights
The Premier Inc. Hospital Quality Incentive Demonstration (PHQID) showed little evidence of reducing care access for minority patients with acute myocardial infarction (AMI), heart failure, or pneumonia. Monitoring of pay-for-performance programs for patient avoidance is still recommended.
Area of Science:
- Health Services Research
- Health Economics
- Health Equity
Background:
- Pay-for-performance (P4P) programs incentivize quality improvements but raise concerns about potential patient selection.
- The Centers for Medicare & Medicaid Services (CMS) and Premier Inc. Hospital Quality Incentive Demonstration (PHQID) is a P4P program that includes public quality reporting.
Purpose of the Study:
- To determine if the PHQID program led hospitals to avoid treating minority patients with acute myocardial infarction (AMI), heart failure, or pneumonia.
- To assess if the PHQID program influenced the provision of coronary artery bypass graft (CABG) surgery to minority patients with AMI.
Main Methods:
- Analysis of 100% Medicare inpatient claims, denominator files, and provider of service files from 2000 to 2006.
- Comparison of the conditional probability of receiving care at PHQID hospitals for specific conditions before and after program implementation, stratified by race.
- Assessment of differences in CABG receipt for AMI patients between white and minority groups in PHQID-participating versus non-participating hospitals.
Main Results:
- Little evidence was found that the PHQID reduced access for minority patients.
- A significant reduction in adjusted admissions for "Other Race" beneficiaries was observed for AMI, but not for heart failure or pneumonia.
- Marginally significant evidence (p<.10) suggested a reduction in CABG for "Other Race" beneficiaries.
Conclusions:
- The PHQID program demonstrated minimal evidence of minority patient avoidance.
- Continued monitoring of patient avoidance is recommended for future pay-for-performance initiatives to ensure equitable care access.
Objective:
To examine whether the CMS and Premier Inc. Hospital Quality Incentive Demonstration (PHQID), a hospital-based pay-for-performance (P4P) and public quality reporting program, caused participating hospitals (1) to avoid treating minority patients diagnosed with acute myocardial infarction (AMI), heart failure, and pneumonia and (2) to avoid providing coronary artery bypass graft (CABG) to minority patients diagnosed with AMI.
Data Sources:
One hundred percent Medicare inpatient claims, denominator files, and provider of service files from 2000 to 2006.
Study Design:
We test for differences in the conditional probability of receiving care at PHQID hospitals for AMI, heart failure, and pneumonia before and after implementation of the PHQID between white and minority patients. We also test for differences in the conditional probability that white and minority patients diagnosed with AMI receive CABG in hospitals participating, and not participating, in the PHQID before and after the implementation of the PHQID.
Data Extraction Methods:
Data were obtained from CMS.
Principal Findings:
We find little evidence that the PHQID reduced access for minority patients: only "Other Race" beneficiaries had a significant reduction in adjusted admissions to PHQID hospitals in the postperiod, and only for AMI. Only marginally significant ( p<.10) evidence of a reduction in CABG was found, also occurring for Other Race beneficiaries.
Conclusions:
Despite minimal evidence of minority patient avoidance in the PHQID, monitoring of avoidance should continue for P4P programs.
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