Studies examine how hospital payments for cardiovascular care may affect patient outcomes

BOSTON -- In recent years, there has been a growing emphasis on improving the value of health care by incentivizing reduced spending and improved outcomes.  One such effort is the Hospital Value-Based Purchasing Program administered by the Centers for Medicare and Medicaid Services (CMS). The program makes payments to hospitals based on several measures, including average spending for an episode of care and mortality rates for certain conditions, such as acute myocardial infarction (AMI), or heart attack. Hospitals that perform poorly in these measures receive reduced payments.

A new, large-scale study – led by researchers at the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center (BIDMC) and published online on March 14 in Circulation: Cardiovascular Quality and Outcomes – examined the relationship between 30-day episode spending for inpatient and post-discharge care and patient mortality following a hospital admission for heart attack.

“Pay-for-performance programs such as the Hospital Value-Based Purchasing Program have recently been under fire given the absence of strong evidence that they actually improve care quality,” said first author Rishi K. Wadhera, MD, MPhil, an investigator at the Smith Center at BIDMC and a cardiology fellow at Brigham and Women’s Hospital. “In this study we found that higher 30-day spending to care for Medicare beneficiaries who recently experienced a heart attack was associated with a modest reduction in patient mortality.”

Using national Medicare claims data, the researchers examined more than 640,000 hospitalizations involving patients 65 years or older hospitalized for heart attack at an acute care hospital between July 2011 and June 2014.

“Recent policy efforts have focused on improving the value of care, both in terms of total spending and patient outcomes,” said senior corresponding author Robert W. Yeh, MD, MSc, Director of the Smith Center for Outcomes Research in Cardiology at BIDMC.  “We need to understand whether programs like the Hospital Value-Based Purchasing Program are able to globally reduce spending and improve outcomes for acute conditions like AMI, or whether the strong incentive to reduce hospital spending has unintended adverse consequences.”

“These findings have important implications for patient care,” said Wadhera. “While this study found that increased spending was associated with better outcomes, not all spending is of equal value and further research is needed to find out why higher-spending hospitals have better outcomes.”

In addition to Wadhera and Yeh, study coauthors include Smith Center researchers Yun Wang, PhD, and Changyu Shen, PhD; Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital Heart & Vascular Center; and Karen E. Joynt Maddox, MD, MPH, of Washington University School of Medicine.

This work was supported by National Institutes of Health Training Grant T32HL006704-32.

Updated: Separate study reviews hospital payments for heart failure and effects on patient outcomes

In a similar study published online on April 11 in JACC: Heart Failure, Drs. Yeh and Wadhera examined the association of patient outcomes with 30-day payments for an episode of heart failure (HF) care at the hospital level. Using national Medicare claims data, the researchers examined 1,343,792 patients with HF hospitalized from July 1, 2011, through June 30, 2014, across 2,948 hospitals. In summary, the researchers found that higher hospital-level 30-day payments following an admission for HF are associated with a lower likelihood of patient mortality.

Given the high and rising prevalence of HF and its associated financial burden in the United States, policymakers are putting more attention toward improving value for HF care. HF is the most common cause of hospitalization among Medicare beneficiaries and accounts for a large sum of total Medicare expenditures; however, mortality rates remain high, and improvements have slowed in recent years. As value-based and alternative payment models increasingly spur hospitals to both reduce spending and improve outcomes for HF, it is essential to understand how payments for an episode of HF care are related to clinical outcomes.

“Both studies highlight the challenges institutions may face as they are increasingly held financially responsible for both payments and outcomes associated with an episode of HF care or heart attack care through value-based and alternative payment programs,” said Robert W. Yeh, MD, MSc, Director of the Smith Center for Outcomes Research in Cardiology at BIDMC. “Further research is needed to identify interventions that improve outcomes, both during and following hospitalization, to ensure that hospitals continue to invest in procedures, services, and resources that improve survival, while cutting wasteful use.”

This work was supported by National Institutes of Health Training Grant T32HL007604-32.