End of Days: A P4P Model in Disguise?

I guess I’m a little out of the swim when it comes to “pop news.” I didn’t catch up to the dire predictions about the world coming to an end until the story was in its third or fourth news cycle. Truth be told, I learned about it on Facebook when a friend lamented that the End of Days, or the Rapture, was expected to occur three days prior to the date she was to defend her doctoral dissertation (“All that work for nothing!”).

In this particular case, being late to the party didn’t matter much. It was pretty easy to catch up on the story. What particularly interested me was how people reacted to it: On one end of the spectrum people were giving away their worldly possessions – presumably to people on the other end of the spectrum, who didn’t buy any of it for a second. I think it safe to say that the distribution of opinion was dramatically skewed in favor of the latter group, although there must have been people in the middle – folks who, for at least a few days, took stock of their lives, reflected on deeds done and not done, and said “I love you” a little more often.

All this got me thinking about behavior in general and the inducements required to modify behavior – or in health care, “practice.” What grabs our attention enough that it causes us to change what we do and how we do it?

The health care industry has tried numerous approaches over the years. We can look as far back as the “Minimum Hospital Standards” established by the American College of Surgeons in 1917, or we can stick to more recent years, during which there has been a dramatic proliferation of efforts to spur changes in practice to drive improvement. The vast majority of these efforts have relied heavily on initiatives that promote transparency and accountability – voluntary reporting, mandated reporting requirements, public release of hospital performance data and independent ranking reports on top hospitals.

While all of these initiatives have yielded improvements in the areas they measure, there is virtual unanimity in the opinion that there is room for further improvement and quite a lot of subscribers to the theory that additional inducement – monetary inducement – will encourage hospitals to close the improvement gaps. And so we find ourselves on the precipice of the first national roll out of a pay-for-performance program, specifically the Centers for Medicare and Medicaid Services' (CMS) Hospital Inpatient Value-based Purchasing (VBP) program, the initial performance period for which begins this July 1. Whether you take the opinion that previous efforts were always meant to lead us here or that we got here because the other efforts didn’t encourage change well enough, there is no disputing the fact that here we are.

In fact, the conversation about the hospital VBP started several years ago, with a 2007 options paper released by CMS. VBP moved from “highly possible” to “absolutely definite” when it was written into the Affordable Care Act of 2010. While the VBP model and methodology has gone through a couple iterations between 2007 and the final rule, released this past April, it really isn’t dramatically different from that first options paper.

So you could say hospitals have had a decent amount of time to prepare. And did they? As was the case with the Rapture, some did; most waited. I say this based on the dramatic uptick in questions to Press Ganey relative to VBP in the last two months now that the methodology and measures have been finalized. We went from light snowfall to avalanche in the blink of an eye.

This comes as no surprise. The external pressures on hospitals are enormous – to VBP we can add several other aspects of payment reform (bundled pricing and accountable care organizations), competitive pressures, rising costs, declining payment, meaningful use, the rise of consumerism and the effects of social media. It’s no wonder that only the “high-hots” get our attention. And in health care, with its ever-squeezed margins, anything involving payment is an automatic high-hot.

Now back to the End of Days. As we saw, after the waiting, it turned out not to be true. (Phew.) The latest news is that they got the date wrong: It’s actually Oct. 21. That may or may not turn out to be the case. So while I will not be giving away my hard-earned, worldly possessions, I think I will take stock, do as much good as possible between now and then, and remember to say “I love you” more often. After all, you never know.