Publication

Article

The American Journal of Managed Care
June 2024
Volume 30
Issue 6
Pages: 276-284

Hospital Strategies in Commercial Episode-Based Reimbursement

This study reports qualitative findings from an explanatory sequential mixed-methods investigation to understand hospitals’ approaches to a novel commercial episode-based reimbursement incentive program.

ABSTRACT

Objectives: To understand hospitals’ approaches to spending reduction in commercial episode-based payment programs and inform incentive design.

Study Design: Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state’s largest commercial payer.

Methods: We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference–based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains.

Results: Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment.

Conclusions: The findings highlighted hospitals’ most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.

Am J Manag Care. 2024;30(6):276-284. https://doi.org/10.37765/ajmc.2024.89561

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Takeaway Points

As commercial payers introduce episode-based reimbursement around hospitalization, there is little known about the effects on hospitals’ strategies and performance. In this qualitative explanatory study, we conducted semistructured interviews with leaders participating in a novel payment incentive from a large commercial insurer. Identifying key themes in their approaches to the program revealed that successful commercial episode-based incentive programs must:

  • be substantive enough to earn attention from hospital leaders or consistent with larger programs to enable synergy;
  • provide opportunity to succeed through both initial improved performance and sustained excellence; and
  • address potential malalignment between hospital objectives and the motivations of credentialed physicians.

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Payers increasingly rely on alternative payment models to hold hospitals accountable for the total cost of episodes around hospitalization. In federal bundled payment programs, hospitals achieved savings1-4 primarily through reduced postacute care spending.5,6 In Michigan, the largest private payer introduced an episode-based incentive program through a statewide quality collaborative. Our evaluation of the initial program years revealed no consistent improvement in spending, with wide performance variation among hospitals.7

Whereas numerous studies have evaluated hospital approaches to large federal incentive programs,1-5 little is known about hospitals’ strategies for episode-based reimbursement in commercial payment models. Yet private payers account for the largest share of US health care spending,8 and their spending patterns are markedly different from those of Medicare due to younger, healthier patients; differences in contracting and market pressures; and lower utilization of postacute care.9 Accordingly, hospitals’ strategies and approaches may differ in commercial episode-based incentive programs. The patterns we observed in performance and outcomes in Michigan are challenging to interpret without direct insights into the behaviors behind the administrative data.

In this study, we capitalized on a unique opportunity to investigate hospital activity within a statewide, private-payer, episode-based incentive program. Our objectives for engaging hospitals participating in the Michigan Value Collaborative (MVC), a statewide consortium of hospitals funded by Blue Cross Blue Shield of Michigan (BCBSM), were to (1) understand how hospitals approached a commercial incentive program, (2) identify best practices for success in episode-based incentives, and (3) inform optimal design of and participation in commercial payment models around hospitalization.

METHODS

Details of the Episode-Based Incentive Program

The MVC-affiliated BCBSM episode-based incentive program is described in detail elsewhere.7 Although participation in MVC is voluntary, nearly all acute care hospitals in Michigan are included. During the study, there were 76 MVC member hospitals, all participating in an episode-based pay-for-performance program based on 30-day total episode spending for 2 clinical conditions selected from 7 options (acute myocardial infarction, congestive heart failure, pneumonia, lower extremity arthroplasty, colectomy, coronary bypass grafting, and spine surgery). This program represents 10% of the overall BCBSM hospital pay-for-performance portfolio, with financial incentives in excess of $200 million per year. Participation in the episode spending component allowed hospitals to select any 2 conditions for which they met minimum case numbers of at least 20 episodes per year. Points toward incentives were earned either by reducing mean episode spending in the performance year vs baseline (“improvement”) or by achieving lower episode spending than peer hospitals in the performance year (“achievement”). Further details of the incentive program are in the eAppendix (available at ajmc.com).

Study Design

This was an explanatory sequential mixed-methods study, as depicted in the Figure. In the previously published quantitative arm,7 we used MVC administrative claims data to evaluate the effect of this incentive program on overall episode spending by hospital and condition. For the qualitative arm reported herein, we recruited leaders from 8 of 76 MVC hospitals, including 4 in the highest quartile of payment incentives (hospitals A-D) and 4 in the lowest quartile (hospitals E-H). We purposively10 selected hospitals with diversity in urbanicity, location, and overall annual payments from BCBSM, including at least 1 large academic hospital and 1 small nonacademic hospital in each group. In each institution, we interviewed MVC champions, who identified 2 to 3 additional individuals knowledgeable about details of their participation. These individuals included administrative leaders (chief operating officer, chief medical officer, or equivalent) and quality officers, with the number of interviewees per hospital varying according to their leadership infrastructure and differences in their roles in the collaborative. Compensation for participation was provided, and an institutional review board of the University of Michigan considered the study exempt from human subjects review.

Interview Guide and Conduct

The interview protocol was informed by MVC experience with BCBSM payment models and research on Medicare bundled payment initiatives11 and then refined during 6 pilot interviews with administrators in the authors’ institution. Interviews included questions on organizational priorities, choice of conditions, components of care within episodes, and care coordination as well as open-ended questions about approaches to episodes of care. We iteratively refined the script, and the final guide consisted of 7 to 10 open-ended questions with specific probes related to primary analytic domains.

An interviewer (S.C.) and subject matter expert (S.E.R.) conducted semistructured interviews through cloud-based audiovisual conferencing between December 2020 and November 2021, taking structured notes within predetermined analytic domains. Interviews were recorded and professionally transcribed. We conducted continuous data monitoring and concluded that we reached saturation at our target 21 interviews, with convergence of themes across hospitals.

Data Analysis

We used rapid qualitative analysis with purposeful data reduction activities without dedicated qualitative software for data management or analysis.12 We composed structured summaries from each interview’s transcripts and notes, which were reviewed by the interviewer, subject matter expert, and qualitative methodologist (S.L.K.). Within-hospital analyses were conducted first, followed by comparisons within performance groups and then across groups using a matrix method to identify themes. Rigor and validity were established through independent review of summaries and matrices by team members with different backgrounds and via group consensus. The study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research.13

RESULTS

We interviewed 21 leaders from 8 hospitals, including 7 administrators (4 in high-performing hospitals, 3 in low-performing hospitals), 9 quality officers (5 and 4, respectively), and 5 MVC site coordinators (3 and 2). Hospitals’ program performance, characteristics, respondents, and selected conditions are in Table 1.

We investigated 4 overarching domains: (1) clinical condition selection approaches, (2) strategies for episode payment improvement, (3) practices for achieving maximum incentives, and (4) obstacles to success in low-performing hospitals. Representative quotations are presented below and in Table 2 [part A, part B, and part C].

Domain 1: Clinical Condition Selection Approaches

Theme 1a: identifiable improvement opportunity. As shown in Table 1, there was no systematic difference by performance group in clinical conditions chosen. Across performance categories, leaders sought identifiable opportunities for quality improvement or historic underperformance: “Areas that we’re not great in…[give] us that much more oomph to try to improve,” said one site coordinator (hospital B, high performing). Another site coordinator (hospital G, low performing) said, “It’s not just about picking…our best service lines…[but rather] where do we have opportunity?”

Theme 1b: synergy with other initiatives. Across hospitals with varying characteristics and performance, conditions were selected because of ongoing value-based improvement efforts with the involved practices and providers. Many hospitals were already participating in related federal value-based purchasing programs: “If we’re already working on something, perhaps there’s an economy of scale there that…we can take advantage of,” said one chief operating officer (hospital A, high performing). Hospitals chose clinical focus areas that were already priorities for their organization: One chief quality officer (hospital G, low performing) said their hospital was “looking at where we already have work that is being done and that this can be an accelerant to that work.… Here is some work that is happening [and] we are putting effort into.… Let’s put that down as our service line.” On the other hand, some chose specialties in which they already performed well, aiming to earn points for achievement rather than improvement: “You want to pick things that you know you are going to get the money for because you are doing it already so well, and you know your outcomes are really good,” said another chief quality officer (hospital C, high performing).

Theme 1c: already-engaged leaders and champions. Both high and low performers chose conditions with engaged physician leaders committed to improvement: “We need to make sure that we have a physician champion…because without that, we’re probably not going to be very successful,” said one site coordinator (hospital A, high performing). For some, physician commitment to hospital-based initiatives was a precondition: “The choices are rooted on the physician engagement of the program and the ability of the quality staff to manage the programs,” said one executive director (hospital E, low performing).

Theme 1d: programmatic constraints. For smaller institutions, condition selection was constrained by admission volumes, if there were few clinical conditions with enough patients to meet analytic minimums: “Many of the things we don’t have enough volume [for]…[so] whatever we qualify for is what I do,” said one site coordinator (hospital C, high performing).

Domain 2: Strategies for Episode Payment Improvement

Theme 2a: data-driven improvement. As participants in a statewide collaborative focused on episode spending, hospitals had access to comprehensive utilization data and risk-adjusted comparisons with peer hospitals. Benchmarking spending against others was often key to motivating improvement: “With the reports by service line that told you…the physician cost, the hospital cost, postacute [cost]…those reports were very helpful,” said one site coordinator (hospital D, high performing). Especially in high-performing institutions, participants noted significant efforts to use administrative and clinical data to motivate performance improvement: “We have a monthly meeting where we review our data…[and] incorporate our service line reports and how we are doing. And then we can better strategize on how…to handle the different conditions,” said one executive director (hospital D, high performing). Others explained that risk-adjusted comparative data highlighted improvement priorities, with one site coordinator (hospital B, high performing) mentioning “having ongoing communication and…data they’re giving us to make sure we’re not working on something that won’t be helpful or that will be a waste of time or not what our population needs.”

Theme 2b: standardization and protocol dissemination. Recognizing the need to promote consistent best practices, respondents described design and dissemination of standardized pathways for conditions of interest, especially at discharge: “We want it to the point where…the person would have to go out of their way to fail…so you can have…consistency once you have trained them in their practice,” said one chief medical officer (hospital C, high performing).

Domain 3: Best Practices for Success in the Incentive Program

Theme 3a: consistent leadership focus on metrics. For institutions highly engaged in this program, there was a commitment to scheduled, periodic attention to key performance indicators and collaborative data: “Our regular meetings focused on reporting…data monthly to all the key stakeholders and just keeping it in the forefront of everyone’s mind to make sure we’re continuing on those core behaviors that we’ve chosen to help us get to our goals,” said one site coordinator (hospital A, high performing). Staff most engaged with the collaborative brought data to leadership as well, with one executive director (hospital D, high performing) mentioning a “committee where all of our senior [leadership], directors, [vice presidents], and [site coordinator] team leads attend, and we bring our performance improvement activities for each of our various service lines [and] departments to this group.”

Theme 3b: readmissions reduction. As seen in federal bundled payment programs, many focused on preventing readmissions to reduce episode spending: “[A] strategic priority for us is top performance in the readmission program.… Readmission is a common thread for most because it is expensive,” said one chief quality officer (hospital G, low performing). Readmissions prevention involved identification of patients with highest needs and candidates for intensified home care: “Our patients [who] frequently readmit were, actually, also candidates for palliative care or hospice care. We coupled that with having a very low utilization of those services in this community,” said another chief quality officer (hospital B, high performing). In other cases, medication adherence and continuity of care were main focus areas: “We saw a lot of ‘frequent flyers.’… We were finding that patients were coming back who didn’t know how to use their inhalers.… [Care coordinator] has been able to mitigate so many things and avoid so many readmissions,” said one MVC site coordinator (hospital H, low performing).

Theme 3c: controlling spending on postacute care. As in federal programs, there was broad interest in managing spending on postacute care: “We do work with…our home care. We collaborate with them in terms of how we are going to manage these patients and what is needed on the home health end.… And then, we also work with our skilled facilities and our transition team…on the total cost of care in the [skilled nursing] facilities,” said one executive director (hospital D, high performing). In institutions self-identified as high utilizers of extended care facilities (ECFs), there was attention to ensuring more careful selection of patients: “You could see in almost any data set…that we were just using this ECF all the time. So the town halls were to meet with local ECFs and talk about…how to put the right patient in the right place and setting for the right reasons at the right time,” said one chief quality officer (hospital F, low performing). There was focus on both the economic case for lesser utilization and the lack of clinical benefit: “We had a big push…to have people not go to nursing homes or rehab…by showing that other facilities were doing it better than we were.… The outcomes were better for people who didn’t go to nursing homes,” said one site coordinator (hospital C, high performing).

Domain 4: Obstacles to Success in Low-Performing Hospitals

Although the approaches and strategies noted above did not appear categorically different between performance groups, low performers did describe more distinct impediments to successful engagement. One noted that their institution failed to maintain focus on cost containment across the measurement period: “And then a year later…we’re back to the original baseline performance from that last project because we didn’t continue to watch it to make sure that it was sustainable and embedded in the operations,” said one chief medical officer (hospital F, low-performing).

Another described competing incentives between institutions and credentialed providers, with nonemployed physicians unmotivated by institutional achievement goals: “I know that there is…an apathy in my group.… They don’t get involved as much in quality initiatives…obviously, you know that is where money talks. But I don’t think…in their pay structure that there is any specific tie,” said another chief medical officer (hospital H, low performing).

DISCUSSION

This analysis represents the qualitative arm of an explanatory sequential mixed-methods14 investigation of approaches to a commercial payer’s episode-based incentive programs. In the quantitative study,7 we found significant variation in performance but little consistent effect on overall spending. Hospitals most likely to achieve high scores selected conditions with high baseline spending and achieved reductions not only in postacute care but throughout episode components. Others have found similar heterogeneity in pay-for-performance outcomes, suggesting that providers were not responding strategically to incentives.15 Comparing respondents from high- and low-performing hospitals in this study, we did not find marked differences in their approaches or strategies to explain their outcomes.

However, the findings around clinical condition choices highlight 2 key insights that can inform design of commercial episode-based incentives. First, the scope of commercial programs is smaller than that of federal initiatives, and there is a limit to hospitals’ bandwidth for improvement efforts. Some interviewees noted high engagement from their institution in this program, significant attention from leadership, and commitment to achievement. Yet most sought overlap with larger initiatives so value improvement efforts could pertain to multiple programs simultaneously. As insurers design incentives, they must weigh alignment with federal programs to allow synergy against customized programs that encourage novel improvement activities.

Second, some hospitals chose conditions with high baseline spending, raising concern for improvement through regression to the mean. In voluntary federal programs with bonuses for savings compared against baseline, hospitals acting strategically have selectively participated in conditions with favorable targets.16 In this BCBSM program, more points were earned from improvement than achievement, suggesting hospitals sought high outlier opportunities rather than high baseline performance, and the highest performers executed this strategy most successfully. Thus, another important program design consideration is the degree to which bonuses can be earned by random variation alone.

Common approaches to episode savings included institutional focus and communication around performance data and standardization of care practices. Although clinical care pathway adherence promotes improvements in outcomes and cost,17-19 hospitals with nonemployed physician staff faced challenges in compliance with pathways due to individual practice variation. Elements most commonly addressed were containment of postacute care and prevention of readmissions, similar to observations from federal bundled payment programs.3,11 These efforts were also consistent with concurrent statewide initiatives within MVC and other collaboratives, demonstrating savings through reduced discretionary postacute care.20,21

Similar strategies have been observed in other studies as well. For example, aligning with our observation that hospitals chose conditions in which they were likely to achieve year-over-year savings, voluntary bundled payment initiatives have attracted highly select hospitals most likely to succeed,22,23 and those most at risk often withdrew.24 Accordingly, the results of pay-for-performance programs have been mixed, with highly variable results,15,25 as we saw in the quantitative arm of this analysis.7 Previous studies examining other pay-for-performance metrics have found that organizational commitment and leadership focus were key factors in high achievement, whereas inadequate resource allocation and data collection have been identified as barriers.26 Rather than defining discrete formulas for success in commercial episode-based models, the conclusion from our data and these studies is that incentivizing high-value behavior requires careful attention to the design of evaluation criteria and the size and characteristics of the incentive itself.

Limitations

These conclusions must be interpreted in the context of several key limitations. First, 21 interviewees from 8 hospitals may not represent the diversity of institutions subject to commercial incentive programs. However, purposive sampling of individuals with varied expertise from institutions with structural and geographical diversity provided a range of respondents and perspectives. Second, because we asked respondents to consider years for which results were already adjudicated, there may be recall bias or conflation with current activities. Third, hospitals participating in unique quality collaboratives in Michigan27 may approach improvement initiatives differently from regions without such programs, and established customs of shared best practices could induce homogeneity. Finally, this study evaluates 1 commercial plan in 1 state. However, BCBSM is the dominant payer in a state diverse in geography, demographics, and economy, representative of the national health care environment. Although details of this program are unique and regional differences in commercial markets, prices, or competition could affect the generalizability of these findings, hospitals’ strategies and practices are most likely to be similar.

CONCLUSIONS

Together with findings from the quantitative arm of this investigation,7 these findings offer important insights into the design of commercial payment models. Effective episode-based incentives need either to be substantive enough to earn attention from hospital leaders or to be consistent with larger programs to enable synergy. They must ensure that hospitals can succeed by remediating underperformance but also have mechanisms to ensure continuing improvements beyond initial program years. Finally, they must address the malalignment between hospital objectives and the motivations of credentialed physicians. As alternative payment models for episodes of care continue to evolve, careful attention to hospital strategies and practices will enable program design to optimize spending and quality. 

Author Affiliations: Department of Surgery (SER), Center for Healthcare Outcomes and Policy (SER, SC, MPT), Department of Cardiac Surgery (MPT), and Department of Internal Medicine (SLK), University of Michigan, Ann Arbor, MI; Michigan Value Collaborative (SER, MPT), Ann Arbor, MI; Center for Clinical Management Research, VA Ann Arbor Health Care System (SLK), Ann Arbor, MI.

Source of Funding: This study and its investigators were funded by the Donaghue Foundation Greater Value Portfolio. Dr Regenbogen was supported by National Institute on Aging K08-AG047252. Drs Regenbogen and Thompson are supported by a contract from Blue Cross Blue Shield of Michigan for the conduct of the Michigan Value Collaborative. Dr Krein is supported by a Department of Veterans Affairs, Health Services Research and Development Service research career scientist award (RCS 11-222). Dr Thompson receives funding from the Agency for Healthcare Research and Quality (K01HS027830, R01HS028397).

Author Disclosures: Dr Regenbogen receives salary support to his institution from Blue Cross Blue Shield of Michigan. Dr Thompson receives partial salary support from Blue Cross Blue Shield of Michigan Value Partnerships for his role as codirector of the Michigan Value Collaborative. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SER, SC, SLK, MPT); acquisition of data (SER, SC); analysis and interpretation of data (SER, SC, SLK, MPT); drafting of the manuscript (SER, SC); critical revision of the manuscript for important intellectual content (SER, SLK, MPT); obtaining funding (SER); administrative, technical, or logistic support (MPT); and supervision (SER).

Address Correspondence to: Scott E. Regenbogen, MD, MPH, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, MI 48109. Email: sregenbo@med.umich.edu.

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