Changes in racial disparities under public reporting and pay for performance Rachel M. Werner
Jan 14, 2016
Changes in racial disparities under public reporting and pay
for performance
Rachel M. Werner
Can market-based QI decrease disparities?
• Disparities stem in part from location of care– Opportunity to reduce disparities by improving
performance among low-quality providers– Public reporting and P4P may reduce
disparities
Market-based QI may increase disparities
• Consumer-driven increases– Limited access to information– Limited access to high-quality providers
• Provider-driven increases– Limited resources to improve quality– Selection of low-risk patients
How does P4P affect resource-poor hospitals?
Werner RM, Goldman LE, Dudley RA. Comparison of change in quality of care between safety-net and non-safety-net hospitals. JAMA 2008;299:2180-2187.
Financial resources are important for QI
• Resource-poor hospitals (i.e. safety-net hospitals) may not be able to invest in quality improvement
• Low-performance at baseline reduces economic rewards
• Rich become richer while poor become poorer
Objective
• To examine changes in disparities in quality of care between safety-net and non-safety-net hospitals under public reporting
• To estimate the financial impact of P4P at safety-net hospitals
Empirical approach
• Publicly available data on hospital performance– www.hospitalcompare.hhs.gov
• All acute care non-federal hospitals in U.S.– 3,665 hospitals– 2004 to 2006
• Compare changes in performance across % safety-net care at hospitals– % Medicaid
Hospital performance measures
3 condition-specific composites:–Acute myocardial infarction
Aspirin at admissionAspirin at dischargeACE-inhibitor for LV dysfunctionBeta-blocker at admissionBeta-blocker at discharge
–Heart failureAssessment of LV functionACE-inhibitor for LV dysfunction
–PneumoniaOxygenation assessmentPneumococcal vaccinationTiming of initial antibiotic therapy
Hospital performance in 2004Percent safety-net:
Adjusted changes in hospital performance
Change in performance (2004 to 2006)
Non-safety-net Safety-net
Difference
Acute myocardial infarction 3.8 2.3 1.5 *
Heart failure 8.0 6.6 1.4 *
Pneumonia 9.3 8.0 1.3 ***
*.05>p-value≥.01; ***p-value<.001
Adjusted for: hospital characteristics, baseline performance, states fixed-effects
Changes in top-ranked hospitals
Low Middle High
% Safety-net
Low Middle High
% Safety-net
Low Middle High
% Safety-net
Changes in top-ranked hospitals
Low Middle High
% Safety-net
Low Middle High
% Safety-net
Low Middle High
% Safety-net
Pay-for-performance simulation
• CMS hospital P4P demonstration project
• In 2004, hospital receive bonuses based on relative performance
• In 2006, hospitals face penalties for not achieving performance above threshold
Changes in % bonus
% Safety-net
Changes in % bonus
% Safety-net
Summary
• Safety-net hospitals had smaller improvements in performance between 2004 and 2006
• Safety-net hospitals were less likely to be identified as top-performers by 2006
• Under P4P, safety-net hospitals would have substantially smaller payments by 2006
Implications
• Hospitals serving a disproportionate share of minority and low income patients are in worse financial condition at baseline
• In setting of public reporting or P4P, widening performance gap could further worsen finances
• Declining finances may further worsen clinical quality
Does “cream-skimming” increase disparities?
Werner RM, Asch DA, Polsky D. Racial profiling: the unintended consequences of coronary artery bypass graft report cards. Circulation. 2005;111:1257-1263
Physician response to public reporting
• In 1991, New York State began publicly rating cardiac surgeons based on their mortality rates
• Composition and risk profiles of patients undergoing CABG has changed– Harder for high-risk patients to find a surgeon
– Schneider and Epstein 1996
– The number and severity of patients transferred out of NY increased
– Omoigui et al 1996
– Lower illness severity of patients receiving CABG in report cards states compared to other states
– Dranove et al 2003
Statistical discrimination
• Because of clinical uncertainty physicians use beliefs about a group to make decisions about an individual
Statistical discrimination in the setting of public reporting
• Physicians may avoid patients with high unmeasured severity
• If surgeons believe racial and ethnic minorities will have worse outcomes, surgeons will preferentially treat white patients after report cards are released
Empirical approach
• All patients admitted with AMI in New York– n = 310,412
• Compared to a national sample of patients admitted with AMI– n = 618,139
• Differences in CABG use between white vs. black and white vs. Hispanic over 2 time periods:– Before report cards (1988-1991)– After report cards (1992-1997)
Changes in racial disparities after public reporting
Summary
• There was a relative increase in disparities in CABG use after public reporting
• No relative change in complements (cardiac catheterization) or substitutes (angioplasty)
• Relative change in CABG use for both blacks and Hispanics
Implications
• Racial/ethnic minorities have lower rates of CABG use before public reporting
• Public reporting may cause increased pressure for physicians to perform well
• If race is a signal for severity, racial disparities may increase– Quality may worsen for subgroups of patients
even as overall quality increases
Reducing racial disparities with market-based incentives
• Changes in financial incentives– Reward improvements in care in addition to
relative rank– Provide direct subsidies for quality
improvement
• Changes in measures– Directly reward reduced disparities– Stratified performance measures