Policy option
CMS adoption
Selective referral
National coverage decisions for selected procedures
Refer patients to specific providers, i.e., “centers of excellence”
Example: Bariatric surgery coverage linked to “center of excellence status”
Non-payment for adverse events
National programs already in place
Incentivize quality improvement by withholding payment for certain adverse outcomes
Examples: In October 2008, CMS discontinued additional payments for certain hospital-acquired conditions that were deemed preventable
Pay for performance
Multiple large pilot programs
Reward providers for high quality or low cost care
Example: Medicare/Premier Pilot for cardiac and orthopedic surgery
Bundled payment
Regional and national pilot programs
Incentivize efficient, coordinated care by bundling payments around an episode
Examples: Medicare Acute Care Episode (ACE) Demonstration Project; and the Center for Medicare and Medicaid Innovation (CMMI) Bundled Payment Pilot Program
Accountable care organizations
Pilot programs
Health care providers accept risk for reducing health care expenditure growth for population of Medicare beneficiaries
Examples: Pioneer Accountable Care Organization (ACO) Demonstration Program; Medicare Shared Savings Accountable Care Organization (ACO) Program
Below we include several examples from the literature that evaluate health care policies. These illustrate many of the concepts discussed above, including how these studies addressed common pitfalls in health policy research.
Example 1
Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. JAMA 2013;309:792–799.
This study from our research group evaluated the impact of the CMS national coverage decision for bariatric surgery, which was the most ambitious selective referral program in surgery to date. In 2006, CMS limited coverage of bariatric surgery to so-called centers of excellence (COEs) as defined by the American College of Surgeons (ACS) and American Society for Metabolic and Bariatric Surgery (ASMBS). Prior studies evaluating the program had shown benefits, with reductions in morbidity and mortality. However, these studies had failed to adequately account for pre-existing trends towards improved outcomes in bariatric surgery. In our study, a control group of non-Medicare patients undergoing bariatric surgery was used to adequately account for these trends. In this differences-in-differences analysis (discussed in detail above), there was no independent effect of the CMS policy on overall complications, serious complications, or reoperations. This study demonstrates the importance of adequately adjusting for pre-existing time trends. Without such an adjustment, policymakers would mistakenly attribute the improved outcomes to the policy.
Key Unanswered Questions
Further research needs to demonstrate the extent to which this policy limited access for Medicare beneficiaries in need of bariatric surgery. It is possible that Medicare patients had to travel further for surgery. Vulnerable populations may experience a decline in availability of surgery if they could not afford to travel away from their homes. Since the policy had no measurable benefit, research demonstrating such harms should strongly motivate CMS to reconsider this policy.
Example 2
The long-term effect of premier pay for performance on patient outcomes. Jha AK, Joynt KE, Orav EJ, Epstein AM. N Engl J Med 2012;366:1606–1615.
This study evaluated the impact of Medicare’s flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), on patient outcomes. Prior studies had demonstrated improved adherence to processes of care with the implementation of the program, but its longer-term impact on risk-adjusted outcomes had not been explored. The authors evaluated 30-day mortality for coronary artery bypass grafting (and other medical conditions) at 252 hospitals participating in the Premier HQID compared to control hospitals that were not participating. They also used a differences-in-differences design to ensure that temporal differences in outcomes were taken into account. They found no improvement in outcomes, beyond existing trends, with the implementation of the pay-for-performance program. From this data, they inferred that other programs modeled after this program, such as the Hospital Value Based Purchasing Program implemented as part of the Affordable Care Act, is unlikely to have meaningful impact on patient outcomes.
Key Unanswered Questions
The important questions around pay-for-performance include whether programs with larger incentives will have an impact on outcomes. As Medicare’s Hospital Value Based Purchasing Program becomes implemented nationally, it will be important to understand if this large program will have benefits. With programs that penalize hospitals for poor outcomes, it will be important to conduct studies to understand whether such policies improve or exacerbate racial and socioeconomic disparities in surgical outcomes.
4.1.3 Surgical Training and Workforce Policy
Policy around surgical training includes the implementation of the 80-hour workweek, which has dramatically changed how we train surgeons in the United States. The motivation for this policy change was the perception that with longer workweeks surgical trainees are fatigued and make more errors that threaten patient safety. This policy change has been written about in numerous studies that assess resident and faculty perceptions about safety. But relatively few studies have addressed the key question: Did this policy have the intended consequences of improving patient safety? We will discuss an example of a paper that examined this question below. However, it is also important to also ask whether the policy had any unintended consequences. For this particular policy, unintended consequences include the potential to make patient safety worse, by increasing hand-offs, and possibly impacting surgical education in way that makes surgical trainees less prepared for independent clinical practice.
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