Payer leverage and hospital compliance with a benchmark: a population-based observational study

<p>Abstract</p> <p>Background</p> <p>Since 1976, Medicare has linked reimbursement for hospitals performing organ transplants to the attainment of certain benchmarks, including transplant volume. While Medicare is a stakeholder in all transplant services, its role in renal transplantation is likely greater, given its coverage of end-stage renal disease. Thus, Medicare's transplant experience allows us to examine the role of payer leverage in motivating hospital benchmark compliance.</p> <p>Methods</p> <p>Nationally representative discharge data for kidney (<it>n </it>= 29,272), liver (<it>n </it>= 7,988), heart (<it>n </it>= 3,530), and lung (<it>n </it>= 1,880) transplants from the Nationwide Inpatient Sample (1993 – 2003) were employed. Logistic regression techniques with robust variance estimators were used to examine the relationship between hospital volume compliance and Medicare market share; generalized estimating equations were used to explore the association between patient-level operative mortality and hospital volume compliance.</p> <p>Results</p> <p>Medicare's transplant market share varied by organ [57%, 28%, 27%, and 18% for kidney, lung, heart, and liver transplants, respectively (<it>P </it>< 0.001)]. Volume-based benchmark compliance varied by transplant type [85%, 75%, 44%, and 39% for kidney, liver, heart, and lung transplants, respectively (<it>P </it>< 0.001)], despite a lower odds of operative mortality at compliant hospitals. Adjusting for organ supply, high market leverage was independently associated with compliance at hospitals transplanting kidneys (OR, 143.00; 95% CI, 18.53 – 1103.49), hearts (OR, 2.84; 95% CI, 1.51 – 5.34), and lungs (OR, 3.24; 95% CI, 1.57 – 6.67).</p> <p>Conclusion</p> <p>These data highlight the influence of payer leverage–an important contextual factor in value-based purchasing initiatives. For uncommon diagnoses, these data suggest that at least 30% of a provider's patients might need to be "at risk" for an incentive to motivate compliance.</p

A New Look at Nonprofits: Health Care Policy in a Competitive Age

The importance of organizational form in American medicine has been the subject of much debate. But the character of the debate-the nonprofit form versus its competitors-has been sufficiently confused that much of the controversy should be reconsidered. That debate has been both ideological (commercialism and profit versus service and professionalism) and practical (which form is more efficient)? The challenge of public policy is to adapt public rules to the central realities of American medicine, not the shibboleths of shrill discourse. In the case of medicine, factors other than the form of legal ownership-among them, the nature of the service provided, the developmental stage of the service, the role of physicians in providing the service, and the nature of government regulation-are more important in fashioning those appropriate responses

Tracing the History of Medicare Home Health Care: The Impact of Policy on Benefit Use

We trace key policy changes that affected use of the Medicare home health benefit from the 1980s through the prospective payment system implemented in 2000, analyzing the impact on three measures of home care use: expenditures, users and visits. We demonstrate the impact of policies generated in the legislative, the judicial, and the executive branches of government and the gaming behavior of home health agencies in response to policy changes. Our analysis suggests that the policy itself and the implementation process are critical to understanding benefit use. The incentives in the policies and agency reactions had the potential to generate fraud in two directions, either over or underuse. Throughout this history, use of the benefit was driven less by patient need than by arbitrary interpretations of eligibility. These interpretations were in turn influenced by opposing ideologies favoring redistribution based on market principles versus those based on need

Strategies for Health Care Cost Containment (1980s-Present)

The U.S. health care system during the past three decades has been over two interrelated questions: first, who will control the manner in which medical care is paid for, and, second, how much will it cost? Many health care experts believe that Medicare\u27s efforts at cost control, primarily in the form of the program\u27s seminal transition to and continual modification of prospective payment of health care providers, has both triggered and repeatedly intensified the economic restructuring of the U.S. health care system. Medicare is an almost $600 billion public health insurance program for individuals sixty-five years of age and older; individuals under sixty-five with certain disabilities (with eligibility depenqent on the severity of the disability and the resultant consequences for a person\u27s ability to work), and those with end-stage renal disease). With regard to how the program reimburses for care, Medicare sets prospectively the payment amount (rates) providers will receive for most covered products and services, and providers agree to accept them as payment in fun, according to the Medicare Payment Advisory Commission. Thus, in most instances, providers\u27 payments are based on predetermined rates and are unaffected by their costs or posted charges

Age-Based Rationing and Technological Development

Comment on Daniel Callahan\u27s Setting Limits