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The ACA: We Got Quantity but What About Quality?

flying cadeuciiOne of the main goals of the Affordable Care Act (ACA), perhaps second only to improving access, was to improve the quality of care in our health system. Now several years out, we are at a point where we can ask some difficult questions as they relate to value and equity. Did the ACA improve quality of care in the ways it intended to? Did it do so for some people, or hospitals, more than others?

How did the ACA Attempt to Improve Quality?

Three particular programs created by the ACA are worthy to note in this regard. The Hospital Acquired Condition Reduction Program (HACRP) took effect on October 1, 2014 and was created to penalize hospitals scoring in the worst quartile for rates of hospital-acquired conditions outlined by the CMS. The Hospital Readmissions Reduction Program (HRRP), which began for patients discharged on October 1, 2012, required CMS to reduce payments to short-term, acute-care hospitals for readmissions within 30 days for specific conditions, including acute myocardial infarction, pneumonia, and heart failure. The Medicare Hospital Value-Based Purchasing Program (HVBP) started in FY2013, was built to improve quality of care for Medicare patients by rewarding acute-care hospitals with incentive payments for improvements on a number of established quality measures related to clinical processes and outcomes, efficiency, safety, and patient experience.

Did Quality Improve?

At first glance, it is tempting to expect that quality might improve through these initiatives. Who can argue with fewer re-admissions, fewer infections caused within hospital walls, and overall greater clinical outcomes, safety, efficiency, and patient satisfaction?

However, recent data suggests that not only is quality improvement hard—it is more confusing and unexpected than we might have realized.

With regards to the HACRP, we currently lack robust outcomes data on the reductions attributable to the program. A 17% decline prior to HACRP implementation in December 2014 further complicates the picture—if there are indeed future reductions in hospital-acquired conditions, are they because of HACRP, or because rates were already on the decline? However, concerning beyond the outcomes that we don’t know are the ones that we do. A recent study in JAMA found that the hospitals most penalized by the HACRP were teaching hospitals, safety-net hospitals, hospitals with the sickest patients based on case-mix indices, and ironically, hospitals with high quality scores on other instruments. Without adequate risk-adjustment, hospitals that are already burdened with the sickest and poorest are also bearing the brunt of financial penalties.

The HRRP has created a similar strain on hospitals with poorer and sicker patients. While readmissions under the HRRP have reduced from 21.5% in 2007 to 17.8% in 2015, Disproportionate Share Hospitals (DSH) are carrying a large share of the penalty burden without appropriate adjustment to their patient characteristics (household income, race, education level, Medicaid status), which are directly related to a higher risk of readmission. The environment a patient returns to is more than likely the cause of their readmission, especially for those in poorer communities that are primarily treated at DSHs.

Recent data unfortunately suggests that the HVBP program has also not shown promising results. HVBP hospitals have not reduced their mortality rates for particularly incentivized conditions relative to pre-HVBP era rates, even when stratifying for hospitals with higher financial incentives, poorer financial health, and greater market competitiveness. Similarly, the HVBP program may not appropriately account for the complexity of patient illness, and thus physicians that care for sicker patients may be subject to financial penalty. Ultimately, this begs the fundamental question that confronts all pay for performance programs: does a financial incentive significantly change the care physicians deliver to patients?

Recommendations and Conclusions

Overall, the ACA’s main quality improvement programs need to be adjusted, particularly to address the likely unintended consequences related to worsening inequity between hospitals treating the wealthy and the poor. This can in some parts be addressed through more thorough risk-adjustment that accounts for socioeconomic patient-level factors and case-mix indices, especially for the HACRP and HRRP. Additionally, the HACRP needs to re-examine its measurement protocols, given the cited incongruence with other quality measures. The HVBP program is a bit more complicated, particularly because we may still not be far enough out to properly assess effects on mortality. Furthermore, we need to more thoroughly examine impacts on morbidity as well. The HVBP might benefit from moving away from multiple specific measures of quality, and find a way to look more holistically at the overall picture of care. It must also account for the complexity of patient care delivered at the individual level so as to reward, rather than punish, physicians caring for our nation’s sickest and most complex.

Quality improvement is a complicated issue, largely because quality has a different meaning to every patient and every provider. However, in the effort to improve quality, the ACA, as related to the three specific programs highlighted, has at best shown that P4P initiatives have much to improve upon, and at worse has caused harm to hospitals caring for the sickest and most complicated patients. This, I am certain, is not an improvement, although it carries an important lesson: in creating measures to improve care, we must be careful to first do no harm, especially to the least well off in our healthcare system and those caring for them.

Abraar Karan MD is an MPH candidate in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.

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