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CMS Measures Have Limited Impact on Patient Experience Levels

Since tying patient experience scores to Value-Based Purchasing incentives, improvement rates have plateaued, research shows.

By Sara Heath

CMS has played a significant role in emphasizing positive patient experience, notably by tying incentive payments in the Value-Based Purchasing program to patient satisfaction scores. But to what extent have these policy decisions actually improved the patient experience? According to one group of researchers, not much.

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In a study published in the latest issue of Health Affairs, a research team explained that the CMS focus on patient experience scores was born from an effort to improve overall clinical quality, but incremental improvements in scoring metrics have recently leveled off.

“Although focusing on patient experience has been controversial, the bulk of the evidence suggests that high performance on these measures is associated with high performance in other areas of quality, such as clinical processes, patients’ adherence to prevention and treatment, and even health outcomes,” the research team explained.

“Consequently, patients’ perceptions of their health care experiences are increasingly being used as a measure of provider performance in public reporting and pay-for-performance programs.”

The agency’s move to tie parts of VBP payments to CAHPS scores began in 2011. Since then, little work has been done to understand the extent to which this policy decision affected patient experience in hospitals nationwide, the researchers said.

The team assessed patient satisfaction between 2008 and 2014 by examining CAHPS surveys from 3452 hospitals during that time period. Just over 3000 of the hospitals also  participated in the VBP program.

The data showed that patient satisfaction did improve between 2008 and 2014, but those improvements largely happened before CMS introduced VBP incentives.

Over the course of the six-year test period, patient experience improved by an average of 6.1 percentage points. Prior to the VBP program, patient experience improved at a rate of 1.49 percent, and after, measures improved at a rate of 0.55 percent. This indicates that CMS initiatives played only a small role in improving patient care.

These findings rang true of all hospital types, including small versus large and rural versus urban hospitals.

Although the researchers found no concrete reason for the performance improvement plateau, they did offer a few possibilities. For example, part of the problem may be the design of the VBP incentive program.

“The rewards offered to most hospitals under the VBP program are quite modest and thus too small to motivate change, particularly considering the relatively small individual contribution of each of the eight experience measures,” the researchers posited.

Additionally, the program offers incentives either for improvements or high performance, not both categories. This offers little reason for already high-performing hospitals to make improvements.

“Hospitals with high baseline performance have little incentive to invest in improvement, since they will be rewarded through their high achievement already, given that CMS rewards based on the higher of the two components,” the researchers said.

The researchers also suggested a “ceiling effect,” meaning that hospitals may have reached their individual peaks for patient experience improvement.

Patient population characteristics may be one predictor of “ceiling effects,” the researchers said. For example, hospitals serving significant non-English speaking populations may not be able to improve after a certain point because the CAHPS surveys cater primarily to English speakers.

“To put hospitals on a level playing field, policy makers may want to consider further adjusting current measures for additional patient characteristics or to experiment with new measures of patient experience,” the researchers explained.

The team suggested that these results point to further policy changes, especially as the industry continues to call for quality care improvements through value-based payment models.

“Our study suggests that as value-based payment continues to be promoted, it is critical to ensure that payments are structured in ways that lead to better patient experience,” the research team concluded. “Alternative approaches—such as using stronger incentives or more narrowly focused metrics—are needed to clarify how to improve the experience of patients in US hospitals.”

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