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Excited to share our new study in @JAMANetworkOpen-more evidence that value-based incentive programs function as a disproportionate penalty system for safety-net hospitals without meaningful benefits for patients: http://ja.ma/2ZRnrRa
This is #StructuralRacism in action.
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This is #StructuralRacism in action.
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2/ Value-based incentive programs aim to 
healthcare quality and 
cost by linking $$ (incentives or penalties) to hospital performance (sounds great, right?), but there can be unintended consequences for safety-net hospitals & their patients. http://shorturl.at/iqvIJ
healthcare quality and cost by linking $$ (incentives or penalties) to hospital performance (sounds great, right?), but there can be unintended consequences for safety-net hospitals & their patients. http://shorturl.at/iqvIJ
3/ First, what is a safety-net hospital? By mission or mandate, safety-net hospitals provide healthcare to a disproportionate share of people without the means to pay or who are insured by Medicaid. https://www.bmc.org/healthcity/policy-and-industry/critical-role-safety-net-health-systems-podcast
4/ Because of #StructuralRacism, safety-net hospitals care disproportionately for Black, Latinx, Indigenous, and other people of color. Here’s a good primer if you want more historical background: https://www.theatlantic.com/politics/archive/2016/05/americas-health-segregation-problem/483219/
5/ Safety-net hospitals have lower operating margins AND are more likely to be penalized when participating in value-based incentive programs than non-safety-net hospitals: https://bit.ly/3eq006A and https://jamanetwork.com/journals/jama/fullarticle/2411284
6/ Our study looked at 2 federal value-based incentive programs that target healthcare-associated infections: Hospital Value-Based Purchasing ( #HVBP) & Hospital-Acquired Conditions Reduction Program ( #HACRP). If you're interested, here's how HACRP works:
7/ We used an interrupted time series design to assess the association between #HACRP and #HVBP with changes in targeted infection rates in safety-net and non-safety-net hospitals & disparities in infection rates between safety-net and non-safety-net hospitals
8/ We included 618 hospitals that participated in #HVBP & #HACRP and mandated @CDCgov National Healthcare Safety Network healthcare-associated infection surveillance https://www.cdc.gov/nhsn/about-nhsn/index.html
9/ We found:
No change in surveillance-based rates of targeted infections associated with #HVBP & #HACRP in either safety-net or non-safety-net hospitals
Persistent disparities in infection rates (safety-net hospital rates > non-safety-net)
No change in surveillance-based rates of targeted infections associated with #HVBP & #HACRP in either safety-net or non-safety-net hospitals Persistent disparities in infection rates (safety-net hospital rates > non-safety-net)
10/ Why does this matter? If value-based incentive programs don’t improve outcomes & disparities in targeted quality metrics are persistent, then the programs are functioning as a disproportionate penalty system for the safety-net without any demonstrated benefit to patients.
11/ Disproportionate financial penalization may affect the financial stability of the safety-net & consequently the quality of health care for the patients served (i.e., expect an outsized impact on BIPOC & rural communities). #StructuralRacism
12/ The healthcare safety-net's financial wellbeing is particularly relevant right now: With #COVID19, >5 million Americans lost health insurance in 2020. This is devastating for individuals & will also uncompensated care costs for safety-net hospitals https://www.familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economic-crash-have-caused-the-greatest-health-insurance-losses-in-american-history
uncompensated care costs for safety-net hospitals https://www.familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economic-crash-have-caused-the-greatest-health-insurance-losses-in-american-history
13/ And the CARES Act, even with recent modifications, likely has not sufficiently addressed financial shortfalls for safety-net hospitals
http://disq.us/t/3pouv4y and http://shorturl.at/mIPQR
http://disq.us/t/3pouv4y and http://shorturl.at/mIPQR
14/ Despite #COVID19, planned cuts to Disproportionate Share Hospital (DSH) payments (federal $ meant to offset uncompensated care costs & low Medicaid reimbursement) are continuing mostly unabated ($4 billion in 2021 then $8 billion/yr thru 2025) https://www.aha.org/advisory/2020-03-25-senate-white-house-reach-agreement-relief-package-responding-covid-19
15/ Without even accounting for the COVID19-related shortfalls & increases in uncompensated care, planned cuts to DSH payments will drive the average operating margin of safety-net hospitals into the red https://essentialhospitals.org/institute/essential-data-our-hospitals-our-patients/
16/ So, what to do? Structural problem → structural solutions! We must advocate for:
Stopping ALL planned DSH cuts
More CARES Act attn to safety-net
Medicaid expansion
Medicaid reimbursement
decoupling health insurance & employment https://www.usa.gov/elected-officials
Stopping ALL planned DSH cutsMore CARES Act attn to safety-netMedicaid expansionMedicaid reimbursementdecoupling health insurance & employment https://www.usa.gov/elected-officials
17/ As for #HVBP and #HACRP, we probably need a total overhaul to drive real change, but at minimum, CMS should stratify hospitals by safety-net status before assessing financial penalties & stop double-counting infections in both #HVBP & #HACRP.
18/ Want more research on the healthy equity implications of value-based care? Check out our session @AcademyHealth virtual #ARM20 on 8/4. Also not to miss: 
plenary on 7/28: "Race, Research and the Power and Peril of Big Data" from @ruha9 @RRHDr @ShreyaKangovi & David Asch
plenary on 7/28: "Race, Research and the Power and Peril of Big Data" from @ruha9 @RRHDr @ShreyaKangovi & David Asch
19/19 Thank you to @The_BMC Health City for amplifying! @BUmedicine @AHRQnews @DeptPopMed @GleeHMS @DAGoldmann @StephenSoumerai @ashishkjha https://www.bmc.org/healthcity/research/value-based-payments-incentives-are-not-improving-care-outcomes
