Association between Hospitalist Productivity Payments and High-Value Care Culture
BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses and little is known about the effects of these reimbursements on the local culture of high-value care delivery.
OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals.
DESIGN, PATIENTS, AND SETTINGS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service’s Value-based Purchasing (VBP) scores.
MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression.
RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (β = −6.2, 95% CI −9.9 to −2.5) than if they reported payment with salary or wages.
CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.
© 2019 Society of Hospital Medicine
Productivity Adjustments and High-Value Care Culture
In multilevel regression modeling, hospitalists who reported reimbursement with salary plus productivity adjustments had a lower mean HVCCS score (β = −6.2, 95% CI −9.9 to –2.5) than those who reported payment with salary or wages alone. Further multilevel regression modeling for each HVCCS domain revealed that hospitalists who reported reimbursement with salary plus productivity adjustments had lower scores in the leadership and health system messaging domain (β = −4.9, 95% CI −9.3 to −0.6) and data transparency and access domain (β = −10.7, 95% CI −16.7 to −4.6). No statistically significant difference was found between hospitalists who reported reimbursement with quality or value adjustments.
DISCUSSION
Understanding the drivers that are associated with a high-value care culture is necessary as payment models for hospitals transition from volume-based to value-based care. In this study, we found a meaningful association (β = −6.2) between clinician reimbursement schemes and measures of high-value care culture. A six-point change in the HVCCS score would correspond with a hospital moving from the top quartile to the median, which represents a significant change in performance. The relationship between clinician reimbursement schemes and high-value care culture may be a bidirectional relationship. Fee for service, the predominant payment scheme, places pressure on clinicians to maximize volume, focus on billing, and provide reactive care.7,29 Conversely, payment schemes that avoid these incentives (ie, salary, wages, and adjustments for quality or value), especially if incentives are felt by frontline clinicians, may better align with goals for long-term health outcomes for patient populations and reduce excess visits and services.2-6,8,30-34 At the same time, hospitals with a strong high-value care culture may be more likely to introduce shared savings programs and alternative payment models than those without. Through these decisions, the leadership can play an important role in creating an environment for change.34 Similar to the study sites, hospitals in California have a higher percentage of risk-based payments than hospitals in other states (>22%)35 and may also provide incentives to promote a high-value care culture or affect local physician compensation models.
Hospitals have options in how they choose to pay their clinicians, and these decisions may have downstream effects, such as building or eroding high-value care culture among clinicians or staff. A dose-response relationship between physician compensation models and value culture is plausible (salary with productivity < salary only < salary with value incentive). However, we did not find a statistically significant difference for salary with value incentive. This result may be attributed to the relatively small sample size in this study.
Hospitals can also improve their internal processes, organizational structure, and align their institutional payment contracts with those that emphasize value over fee-for-service-based incentives to increase value in care delivery.36 The operation of hospitals is challenging when competing payment incentives are used at the same time,7 and leadership will likely achieve more success in improving a high-value care culture and value performance when all efforts, including clinician and institutional payment, are aligned.37-38
Enduring large systems redesign will require directing attention to local organizational culture. For the majority of individual HVCCS items, 30% or more hospitalists across all sites agreed or strongly agreed that components of low-value care culture exist within their institutions. This response demonstrates a lack of focus on culture to address high-value care improvement among the study sites. Division and program leaders can begin measuring culture within their groups to develop new interventions that target culture change and improve value.34 No single panacea exists for the value improvement of hospitalist programs in California across all hospital types and sites.
Unique trends, however, emerge among each hospital type that could direct future improvements. In addition to all sites requiring increased transparency and access to data, community-based hospitalists identified the need for improvement in the creation of a blame-free environment, comfort with cost conversations, and aspects of leadership and health system messaging. While a high proportion of these hospitalists reported a work culture and role modeling that support the delivery of quality care at low costs, opportunities to create open discussion and frontline involvement in improvement efforts, weigh costs into clinical decision making, and cost conversations with patients exist. We hypothesize that these opportunities exist because community-based hospitals create infrastructure and technology to drive improvement that is often unseen by frontline providers. University-based hospitalists performed higher on three of the four domains compared with their counterparts but may have opportunities to promote a blame-free environment. A great proportion of these hospitalists reported the occurrence of open discussion and active projects within their institutions but also identified opportunities for the improvement of project implementation. Safety-net hospitalists reported the need to improve leadership and health system messaging across most domain items. Further study is required to evaluate reasons for safety-net hospitalists’ responses. We hypothesize that these responses may be related to having limited institutional resources to provide data and coordinated care and different institutional payment models. Each of these sites could identify trends in specific questions identified by the HVCCS for improvement in the high-value care culture.25
Our study evaluated 12 hospitalist programs in California that represent hospitals of different sizes and institutional VBP performance. A large multisite study that evaluates HVCCS across other specialties and disciplines in medicine, all regions of the country, and ambulatory care settings may be conducted in the future. Community-based hospitalist programs also reported low mean HVCCS scores, and further studies could better understand this relationship.
The limitations of the study include its small subgroup sample size and the lack of a gold standard for the measurement of high-value care. As expected, hospitalist groups among safety-net hospitals in California are small, and we may have been underpowered to determine some correlations presented by safety-net sites when stratifying by hospital type. Other correlations also may have been limited by sample size, including differences in HVCCS scores based on reimbursement and hospital type and the correlation between a blame-free environment and reimbursement type. Additionally, the field lacks a gold standard for the measurement of high-value care to help stratify institutional value performance for site selection. The VBP measure presents policy implications and is currently the best available measure with recent value data for over 3,000 hospitals nationally and representing various types of hospitals. This study is also cross-sectional and may benefit from the further evaluation of organizational culture over time and across other settings.
