Negative Incentives

Traditional P4P programs offer financial bonuses for achieving quality markers. But there is a new trend on the rise that adds a stick to the carrot. Medicare’s no-pay rule, which explicitly denies payment for 10 hospital-acquired conditions, is leading the way. The rationale behind the no-pay rule is that insurers should not have to reimburse clinicians for medical conditions that result from suboptimal care such as bed sores newly acquired in hospitals. Such “never events” are considered 100% avoidable according to Medicare and should therefore never occur, much less generate greater income. Debate rages over what percentage of which conditions are truly avoidable, rather than over the fairness of the basic concept of “non-payment for never events.” In the articles below, Trapp (234) lists Medicare’s 10 no-pay conditions, Wald (158) critically analyzes non-payment for catheter-associated urinary tract infections, and Schneider (231) reports that CMS bonus payments for e-prescribing will gradually decrease to a penalty for failure to e-prescribe by 2012. Importantly, Streiff (309) argues that non-payment models must recalculate to accommodate for the small amount of patients that will develop many of the proposed "never events," no matter how well patient care is administered.

 

 

Negative Incentives Literature

 

(158) Wald HL, Kramer AW. Nonpayment for Harms Resulting From Medical Care: Catheter-Associated Urinary Tract Infections. JAMA. Commentary. 2007: 298(23) 2782-2784.

PMID: 18165672

Summary:

  • CMS reform will not reimburse for 8 preventable hospital-acquired conditions in a hope to eliminate perverse financial incentives.
  • Commentary focuses on catheter-associated UTI disincentives.
  • There is a risk of overtreatment due to this reform.

Significance to Literature:

Will CMS’ non-payment disincentives decrease the incidence of 8 targeted preventable hospital acquired conditions?

 

 

(231) Schneider ME. Feds Use Carrot Approach To Promote E-Prescribing. Family Practice News. August 1, 2008.

Link: http://www.familypracticenews.com/search/search-single-view/feds-use-car...

Summary:

  • Bonus payments for e-prescribing gradually decrease to a penalty for failure to transmit prescriptions electronically.
  • This is expected to save Medicare up to $156 million over five years by avoiding adverse drug events.
  • Starting in 2012, physicians that do not e-prescribe will have Medicare reimbursement cut by 1%.

Significance to Literature:

This policy allows time for small physician groups to adopt the properly needed technology.

 

 

(234) Trapp D. Final Medicare no-pay rule targets 10 hospital-acquired conditions. American Medical News. August 25, 2008.

Link: http://www.ama-assn.org/amednews/2008/08/25/gvl10825.htm

Summary:

  • CMS is reducing pay for 10 preventable complications, and physicians insist that measures need to be reworked to account for patient risk factors.
  • Physicians also believe that better evidence for some of the guidelines must be shown, specifically, that these complications can be reduced greatly.

Significance to Literature:

This rule could lead physicians and hospitals to be weary of treating high risk patients.

 

 

(309) Streiff MB, Haut ER. The CMS Ruling on Venous Thromboembolism After Total Knee or Hip Arthroplasty. JAMA. Commentary. 2009: 301(10) 1063-1065.

PMID: 19278950 

Summary:

  • Deep venous thrombosis (DVT) was added to the list of never events that CMS will not reimburse for as a complication to total knee and hip arthroplasty.
  • It is estimated that 2.5% of patients properly treated with prophylaxis will still develop DVT, and 1.8% will develop major bleeding complications with prophylaxis.
  • This leaves knee and hip arthroplasty providers financially penalized for providing the surgery.

Significance to Literature:

P4P never events as performance measures must find a way to account for a small percentage of patients that will develop a “preventable” side effect.

 

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