A. A. Brescia1, J. V. Vu1, C. He1, J. Li1, S. D. Harrington2, M. P. Thompson1, E. Norton1, S. Regenbogen1, R. L. Prager1, D. S. Likosky1 2Henry Ford Health System,Detroit, MI, USA 1University Of Michigan,Ann Arbor, MI, USA
Introduction: While healthcare reform efforts have focused on optimizing value (defined as outcomes divided by cost), few studies have focused on identifying how high-value hospitals achieve their performance (i.e., through optimizing quality or cost). We linked clinical and financial data from centers performing coronary artery bypass grafting (CABG) to assess determinants of high-value care.
Methods: Isolated CABG episodes between June 1, 2014 and June 1, 2016 were identified from a statewide administrative database of commercial and government payers (n=2,573 episodes in 33 hospitals) and linked through patient-level data to a clinical registry (used for risk adjustment and clinical outcomes ascertainment). We derived a National Quality Forum endorsed standard composite adverse clinical outcome composed of any of the following: deep sternal wound infection, renal failure, prolonged ventilation, stroke, reoperation, or operative mortality. Hospital value scores were calculated as the proportion of cases without an adverse outcome divided by mean risk-adjusted and price-standardized episode payments. The primary outcome was mean 90-day episode payments (via administrative claims), comprised of index hospitalization, professional, readmission, and post-discharge payment components. We compared total episode payments by value tercile among all patients, and separately among those not developing an adverse outcome.
Results: Among 2,573 patients, mean episode payments were $47,749 and 272 (10.6%) patients experienced an adverse outcome. Percentage of Medicare CABG patients, teaching hospital status, and urban location did not differ between hospital terciles. Hospitals in lowest value tercile (T1) compared to highest value tercile (T3) had longer mean length of stay (LOS) [10.3 vs 8.6 days, p=0.031]. Episode payments were higher in T1 than T3 ($51,194 vs $44,117, p<0.001), driven by $3,212 higher index hospitalization (p<0.001), $1,132 higher professional (p=0.004), and $1,996 higher readmission payments (p=0.016). After stratifying patients who did not experience an adverse outcome, episode payments remained higher in T1 as compared to T3 ($48,014 vs $43,107, p=0.004) [Figure], driven by $722 higher professional services (p=0.024) and $1,408 higher post-discharge payments (p=0.023).
Conclusions: High value hospitals achieved lower episode spending both by optimizing use of potentially discretionary care, in addition to preventing adverse clinical outcomes. Among patients without an adverse outcome, high-value centers had lower total episode, professional, and post-discharge payments. These findings identify sources of modifiable payment variation and may inform approaches to bundled payments and value-based reimbursement.
