An Environmental Scan of Pay for Performance in the Hospital Setting: Final Report. Measures


  •  Define the set of services provided in the outpatient hospital setting to identify what could be measured and potentially rewarded.
  •  What measures of performance (e.g., clinical effectiveness, efficiency, patient experience, care coordination/transitions) are currently being used for   both inpatient and outpatient hospital care in practice, demonstrations, etc.? 
  •  How do measures of performance used in practice and in demonstrations differ from and align with recommendations concerning P4P and public reporting from such sources as the IOM, MedPAC, JCAHO, AHRQ?
  •  What are the benefits of and barriers to the use of different types of measures in a Medicare hospital P4P plan, including process (e.g., current HQA measures), outcomes (e.g., mortality), patient survey (e.g., HCAHPS), administrative (e.g., AHRQ PSIs), and structural measures (e.g., the structural Leapfrog Group measures recommended in DRA Section 5001(a) as the “starter set” of hospital measures as defined in the IOM report “Performance Measurement: Accelerating Improvement”)?
  •  What criteria are existing hospital P4P programs and public reporting activities using to select measures? What are the salient differences, if any, in the criteria used in P4P and public reporting programs? What standards are used in these programs to assess the extent to which a measure is associated with improved processes or outcomes of care?
  •  How are programs addressing methodological issues around P4P, including level of aggregation of measures (i.e., composite scoring, weighting), establishment of benchmarks versus thresholds versus targets, risk adjustment, and opportunities for gaming?
  •  How should the burden of data collection factor in as a criterion for selection of measures or topics?
  •  How do existing P4P or public reporting systems assess the accuracy of the data they receive? Do they validate a provider’s general ability to provide accurate data, or do they audit or otherwise certify the accuracy of specific data transmissions? How does the quality assurance strategy affect the selection of particular measures or topics?
  •  What are the process, criteria, and timeline for modification/maintenance of P4P measures, including adding, changing, retiring, rotating, or deleting measures in a P4P environment and giving hospitals and other stakeholders adequate notice of measure modifications? How can maximum flexibility be built into the process to allow for quick response to new evidence in order to modify both the individual measures and the associated payment incentives?
  •  What approaches are more or less successful for involving stakeholders in the identification, maintenance, and future expansion of P4P and public reporting measure sets (e.g., HQA, JCAHO, NQF, hospital systems, specialty societies, individual hospitals)?
  •  How should “new” measures be introduced in P4P? Is public reporting (with or without an incentive) a necessary precursor or transition step for all measures used in a P4P approach?
  •  If public reporting is not a prerequisite, should the process include a dry run (a period during which hospitals gain experience with reporting the measure prior to its use for P4P)?
  •  What are the longer-term needs for new areas of measure development? Issues to be considered include how to create measures that address both the inpatient and the outpatient hospital setting; patient safety, overuse, medication use, appropriateness, readmissions, complications, efficiency, equity, coordination of care across settings; and other identified “measure gaps” pertinent to P4P.
  •  What processes need to be established to assure alignment and convergence of standardized measures of hospital performance across the hospital industry?
  •  What can other P4P arrangements suggest about how a Medicare hospital P4P and public reporting plan could align with and promote similar objectives in other settings (e.g., physician practice, post-acute settings)?

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