Patient perspective should be included in CMS' reward system for hospitals: study

One of the methods used to gauge hospital performance needs to stop giving equal weight to the four metrics it uses and, in addition, start including patient feedback in its calculations, according to a study in JAMA Network Open.

Researchers at the University of California and St. Paul’s Hospital in Canada looked at the Hospital Value-Based Purchasing (HVBP) program overseen by the Centers for Medicare & Medicaid Services (CMS) and question whether the process used to reward quality in hospitals might be flawed and, if so, how it might be fixed.

HVBP is based on four metrics: outcomes, safety, patient experience and efficiency. In the online survey conducted in March 2022 of 1,025 Medicare beneficiaries, 49% said that clinical outcomes mattered most to them. That was followed by safety (22%), patient experience (21%) and efficiency (8%).

Logan Trenaman, Ph.D., of St. Paul’s Hospital in Vancouver, Canada, and the study’s corresponding author, told Fierce Healthcare in an email that he wanted to find out whether the HVBP program's values match up with patients' values.

“Do patients feel that clinical outcomes are equally important as patient experience?” Trenaman said. “As safety? The results suggest that the most important aspect of hospital quality to patients is clinical outcomes (it is about twice as valuable as patient experience and safety, and considerably more valuable than efficiency).”

HVBP, one of CMS’s longest-running value-based payment programs, reduces operating payments to hospitals by 2% a year, or nearly $2 billion, and redistributes that according to how well they deliver the four metrics. The hospitals can get less, more or the same amount that had been withheld, depending on how well they do. However, there’s doubt among experts about just how much motivation this system provides, and the researchers cite data that suggest that HVBP does little to improve hospital quality.

“If the current incentives are insufficient to motivate hospitals to make investments to improve care, it is unlikely that using beneficiary value weights within the current incentive structure (ie, 2% of payments) would motivate change,” the study said. “Indeed, the change in incentive payments when modifying value weights for most hospitals actually represents a relatively modest amount of the 2% that is withheld.”

Trenaman said that he hopes his study raises questions not only about just how patient input should be included in HVBP design, but also about the four chosen domains. “Does it just need to be four?” he asked. If HVBP includes additional domains, what would they be and how would they be measured?

One way to give patient feedback more impact concerning hospital performance would be to expand the Hospital Consumer Assessment of Healthcare Providers and Systems patient-reported experience measure, already used in the HVBP process, to include routinely collected patient feedback on outcomes and/or safety.

HVBP can create or exacerbate racial disparities in healthcare, the study said. For instance, hospitals that serve a higher proportion of Black patients might be penalized more even when data aggregators account for regional characteristics and safety-net status. They note that eliminating racial and ethnic disparities had not been included in the original HVBP design, and there’s no guarantee that including beneficiary feedback would mitigate that situation.

However, the study states that “establishing health equity as an explicit objective of value-based payment reforms and tying equity to payments can be accomplished by incorporating equity measures into assessment and/or modifying the payment criteria to assign a greater weight to quality improvement rather than quality achievement.”

Trenaman said that “there have been longstanding concerns about the potential for value-based payment programs and reforms to increase disparities. We found that using patients' value weights (rather than the current equal weights) would have a disproportionately negative impact on incentive payments to smaller, lower-volume hospitals. This evidence highlights an important ‘tension’ whereby considering patients’ perspectives could actually increase disparities. I think it is critical to apply this equity lens, and we have generated evidence that can inform the ongoing debate around potential reforms.”

Researchers point to CMS’s unveiling this year of the Accountable Care Organization Realizing Equity, Access, and Community Health (REACH) model, which aims to improve both quality and equity.

That patients place greater value on outcomes, experience, and safety should be no surprise because CMS bears the cost for efficiency, the study states. CMS, for its part, needs to ensure the efficient allocation of limited resources to improve care for as many Medicare beneficiaries as possible.

“Integrating these perspectives is possible,” the study said. “For example, beneficiary value weights could be used for the outcomes, safety, and patient experience domains, whereas Medicare could set the weight for the efficiency domain. Furthermore, the perspectives of other key stakeholders, such as hospitals, could be considered and incorporated into the program design.”

Trenaman said that he thinks that the patient perspective should be included in the HVBP but stresses that's his personal opinion. “I also feel that other perspectives should also be considered,” he said. “These might include the perspectives of Medicare (the payer), hospital administrators, and physicians (among others). One challenge moving forward is how do we ‘integrate’ these different perspectives?”

In addition, he points out that he and his team focused on one of CMS’s value-based programs when there are plenty of others to consider.

“I think we should also be considering how patient’s perspectives could be incorporated into these programs as well,” he said.