Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study

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Background:
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.

Methods and Findings:
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's “Value-Based Purchasing” program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.

Conclusions:
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

: Please see later in the article for the Editors' Summary

Vyšlo v časopise: Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study. PLoS Med 7(6): e32767. doi:10.1371/journal.pmed.1000297
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pmed.1000297

Souhrn

Zdroje

1. RolandM

2004 Linking physicians' pay to the quality of care — A major experiment in the United Kingdom. New Engl J Med 351 1448 1454

2. ScottIA

2007 Pay for performance in health care: strategic issues for Australian experiments. Med J Australia 187 31 35

3. ChengT-M

2009 Lessons from Taiwan's universal national health insurance: a conversation with Taiwan's Health Minister Ching-Chuan Yeh. Health Aff 28 1035 1044

4. RosenthalMB

FernandopulleR

SongHR

LandonB

2004 Paying for quality: providers' incentives for quality improvement. Health Aff 23 127 141

5. US Department of Health and Human Services, Centers for Medicare and Medicaid Services 2007 Report to Congress: plan to implement a Medicare hospital value-based purchasing program. November 2007. Available: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf. Accessed 5 November 2008

6. US Department of Health and Human Services, Centers for Medicare and Medicaid Services 2009 Roadmap for implementing value driven health care in the traditional Medicare fee-for-service program. January 9, 2009. Available: http://www.cms.hhs.gov/QualityInitiativesGenInfo/downloads/VBPRoadmap_OEA_1-16_508.pdf. Accessed 8 July 2009

7. MayesR

BerensonRA

2006 Medicare prospective payment and the shaping of U.S. health care Baltimore Johns Hopkins University Press

8. RogerFH

2003 Case mix use in 25 countries: a migration success but international comparisons failure. Int J Med Inform 70 215 219

9. LewinME

AltmanSH

Institute of Medicine (US) Committee on the Changing Market 2000 America's safety net: intact but endangered Washington (D.C.) National Academy Press

10. BazzoliGJ

ClementJP

LindroothRC

ChenH

AydeyeSK

2007 Hospital financial condition and operational decisions related to the quality of care. Med Care Res Rev 64 148 168

11. RickettsTC

2005 Workforce issues in rural areas: a focus on policy equity. Am J Public Health 95 42 47

12. RosenblattRA

AndrillaCHA

CurtinT

HartLG

2006 Shortages of medical personnel at community health centers: implications for planned expansion. JAMA 249 1042 1049

13. American College of Physicians 1995 Rural primary care. Ann Intern Med 122 380 390

14. MasseyDS

1996 The age of extremes: concentrated affluence and poverty in the twenty-first century. Demography 33 395 412

15. World Bank 2005 World Bank development report 2006: equity and development Washington (D.C.) World Bank

16. BerryCR

GlaeserEL

2005 The divergence of human capital level across cities. Papers Region Sci 84 407 444

17. RauchJE

1993 Productivity gains from geographic concentration of human capital: evidence from the cities. J Urban Econ 34 380 400

18. AcsZJ

ArmingtonC

2004 The impact of geographic differences in human capital on service firm formation rates. J Urban Econ 56 244 278

19. KrumholtzHM

MerrillAR

SchoneEM

SchreinerGC

ChenJ

2009 Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation cardiovascular quality and outcomes, published online July 9, 2009. Available: http://circoutcomes.ahajournals.org. Accessed 11 July 2009

20. RyanA

2009 Hospital-based pay-for-performance in the United States. Health Econ 18 1109 1114

21. TenenbaumSJ

2009 Pay for performance in Medicare: evidentiary irony and the politics of value. J Health Politics, Policy and Law 35 717 746

22. Hospital Compare Database Available www.hospitalcompare.hhs.gov. Accessed 1 January 2009

23. Medicare Cost Reports (MCR) 2003 US Department of Health and Human Services, Center for Medicare and Medicaid Services. Available: http://www.cms.hhs.gov/CostReports. Accessed 2 May 2009

24. Area Resource File (ARF) 2007 Rockville (Maryland): US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions

25. WachterRW

FlandersSA

FeeC

PronovostPJ

2008 Public reporting of antibiotic timing. Ann Intern Med 149 29 32

26. Centers for Medicare and Medicaid Services and the Joint Commission. Specifications manual for national hospital quality measures. Available: www.qualitynet.org. Accessed 10 October 2009

27. WernerRM

GoldmanLE

DudleyRA

2008 Comparison of change in quality of care between safety-net and non–safety-net hospitals. JAMA 299 2180 2187

28. JhaAK

OravJE

ZhengJ

EpsteinAM

2008 The characteristics and performance of hospitals that care for elderly hispanic Americans. Health Aff 27 528 537

29. Hasnain-WyniaR

BakerDW

NerenzD

FeinglassJ

BealAC

2007 Disparities in health care are driven by where minority patients seek care: examination of the Hospital Quality Alliance measures. Arch Intern Med 67 1233 1239

30. CMS HQI Demonstration Project: composite score methodology overview. Available: http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalCompositeQualityScoreMethodologyOverview.pdf. Accessed 30 October 2008

31. Shortage Designation: HPSAs, MUAs & MUPs. Health Resources and Services Administration. Available: http://bhpr.hrsa.gov/shortage. Accessed 30 October 2008

32. US rurality: 2004 typology codes. US Department of Agriculture website. Available: http://www.ers.usda.gov/briefing/rurality/typology/. Accessed 30 October 2008

33. AyanianJZ

WeissmanJS

2002 Teaching hospitals and the quality of care. Milbank Quart 80 267 593

34. BelsleyDA

KuhE

WelschRE

1980 Regression diagnostics: identifying influential data and sources of collinearity New York John Wiley and Sons

35. BradleyEH

CurryLA

WebsterTR

MatteraJA

RoumanisSA

2006 Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. Circulation 113 1079 1085

36. BradleyEH

HerrinJ

MatteraJA

HolmboeES

WangY

2005 Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care 43 282 292

37. BradleyEH

HolmhoeE

MatteraJA

RoumaisSA

RadfordMJ

2001 A qualitative study of increasing beta-blocker use after acute myocardial infarction: why do some hospitals succeed? JAMA 285 2604 2611

38. DevarajS

KohliR

2003 Performance impacts of information technology: is actual usage the missing link? Manage Sci 49 273 289

39. EllerbeckEF

BhimarajA

HallS

2006 Impact of organizational infrastructure on beta blocker and aspirin therapy for acute myocardial infarction. Am Heart J 152 579 584

40. GoldmanLE

HendersonS

DohanDP

TalaveraJA

DudleyRA

2007 Public reporting and pay-for-performance: safety-net hospital executives' concerns and policy suggestions. Inquiry 44 137 145

41. MilgateK

ChengSB

2006 Pay for performance: the MedPAC perspective. Health Aff 25 413 419

42. PisarskiAF

2007 Real numbers: commuting in America. Issues Sci Technol 23 76 80

43. National Association of Counties. An overview of county government. Available: http://www.naco.org/Content/NavigationMenu/About_Counties/County_Government/A_Brief_Overview_of_County_Government.htm. Accessed 20 January 2010

44. CasalinoLP

EsterA

EisenbergA

LewisE

MontgomeryJ

2007 Will pay for performance and quality reporting affect health care disparities? Health Aff 26 x405 w414

45. BlusteinJ

2008 Who is accountable for racial equity in health care? JAMA 299 814 816

46. ChopraM

MunroS

LavisJB

VistG

BennettS

2008 Effects of policy options for human resources for health: an analysis of systemic reviews. Lancet 371 668 674

47. World Health Organization 2009 Report from the joint WHO/AAAH conference on getting committed health workers to underserved areas: a challenge for health systems Geneva WHO. Available: http://whqlibdoc.who.int/hq/2009/WHO_HRH_HMR_2009.06_eng.pdf. Accessed 30 March 2010

48. DoranT

FullwoodC

KontopantelisE

ReevesD

2008 Effect of financial incentives on inequalities in the deliver of primary care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 372 728 736

49. Department of Health, National Health Service General Medical Services 1990 Statement of fees and allowances payable to general medical practitioners in England and Wales from 1 April 1990. London: Department of Health, 1990. Available: http://www.sfa.scot.nhs.uk/. Accessed 20 January 2010

50. Medicare Rural Hospital Flexibility Program. The Social Security Act, Title XVIII, Sections 1814 and 1820. Available: http://www.ssa.gov/OP_Home/ssact/title18/1820.htm. Accessed 30 March 2010

51. Felt-LiskS

GimmG

PetersonS

2007 Making pay-for-performance work in Medicaid. Health Aff 26 w516 w527

52. FriedmanTL

2005 The world is flat: a brief history of the twenty-first century New York Farrar, Straus and Giroux