Association between Hospitalist Productivity Payments and High-Value Care Culture
BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses and little is known about the effects of these reimbursements on the local culture of high-value care delivery.
OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals.
DESIGN, PATIENTS, AND SETTINGS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service’s Value-based Purchasing (VBP) scores.
MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression.
RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (β = −6.2, 95% CI −9.9 to −2.5) than if they reported payment with salary or wages.
CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.
© 2019 Society of Hospital Medicine
The Centers of Medicare and Medicaid Services (CMS) has introduced new payment models that tie quality and value incentives to 90% of fee-for-service payments and provide 50% of Medicare payments through alternative payment models.1 The push toward value comes after productivity-based physician reimbursement (ie, fee for service) has been associated with poor quality care, including delayed diagnoses, complications, readmissions, increased length of stay, and high costs of care.2-5 The method of physician payment is widely believed to affect clinical behavior by incentivizing doing more, coding for more, and billing for more.6-7 Although payment systems may be used to achieve policy objectives,8 little is known about the association of different payment systems with the culture of delivering value-based care among frontline clinicians.
Culture is defined as a system of shared assumptions, values, beliefs, and norms within an environment and has a powerful role in shaping clinician practice patterns.9-12 The culture within medicine currently contributes to the overuse of resources,11,13 and a culture for improvement is correlated with clinical outcomes. A systematic review found a consistent association between positive organization culture and improved outcomes including mortality.14 Across health systems, institutions with high scores on patient safety culture surveys have shown improvements in clinical behaviors and patient outcomes.15-18
In this study, we aim to describe high-value care culture among internal medicine hospitalists across diverse hospitals and evaluate the relationship between physician reimbursement and high-value care culture.
METHODS
Study Design
This study is an observational, cross-sectional survey-based study of hospitalists from 12 hospitals in California between January and June 2016.
Study Population
A total of 12 hospitals with hospitalist programs in California were chosen to represent three types of hospitals (ie, four university, four community, and four safety net). Safety-net hospitals, which traditionally serve low-income and medically and socially vulnerable patients were defined as those in the top quartile (ie, greater than 0.5) of their Disproportionate Share Index (DSH), which measures Medicaid patient load.19-20
To select hospitals with varying value-based care performance, we stratified using CMS value-based purchasing (VBP) scores from fiscal year 2015; these scores have been used to adjust reimbursement for just over 3,000 hospitals in the VBP program of CMS.22,23 CMS calculates the VBP total performance score as a composite of four domains: (1) clinical processes of care (20% of total performance); (2) patient satisfaction (30%); (3) patient outcomes, including mortality and complications (30%); and (4) cost defined by Medicare payment per beneficiary (20%).21 Established quality measures are based on data reported by participating hospitals and chart abstraction during 2011-2014.22 Although other clinical measures of care intensity have been used as proxies of value-based care,23,24 we used the measure of value that has been publically reported by the CMS VBP given its wide use and effects on reimbursements for 80% of hospitals in the CMS VBP program in 2015.25 We obtained institution-level data from the CMS VBP Program and Hospital Compare files. Each of the three types of hospitals represented institutions with low, middle, and high VBP performance (split in tertiles) as reported by the CMS VBP program. To increase the number of participants in tertiles with fewer hospitalists, a fourth hospital was selected for each hospital type.
We excluded individual hospitalists who primarily identified as working in subspecialty divisions and those who spent less than eight weeks during the last year providing direct patient care on inpatient internal medicine services at the studied institution.
