Abstract
Background
Healthcare
payers in the United States are increasingly tying provider payments to
quality and value using pay-for-performance policies.
Cost-effectiveness analysis quantifies value in healthcare but is not
currently used to design or prioritize pay-for-performance strategies or
metrics. Acute ischemic stroke care provides a useful application to
demonstrate how simulation modeling can be used to determine
cost-effective levels of financial incentives used in
pay-for-performance policies and associated challenges with this
approach.
Methods and Results
Our
framework requires a simulation model that can estimate
quality-adjusted life years and costs resulting from improvements in a
quality metric. A monetary level of incentives can then be
back-calculated using the lifetime discounted quality-adjusted life year
(which includes effectiveness of quality improvement) and cost (which
includes incentive payments and cost offsets from quality improvements)
outputs from the model. We applied this framework to an acute ischemic
stroke microsimulation model to calculate the difference in
population-level net monetary benefit (willingness-to-pay of $50 000 to
$150 000/quality-adjusted life year) accrued under current Medicare
policy (stroke payment not adjusted for performance) compared with
various hypothetical pay-for-performance policies. Performance
measurement was based on time-to-thrombolytic treatment with tPA
(tissue-type plasminogen activator). Compared with current payment,
equivalent population-level net monetary benefit was achieved in
pay-for-performance policies with 10-minute door-to-needle time
reductions (5057 more acute ischemic stroke cases/y in the 0–3-hour
window) incentivized by increasing tPA payment by as much as 18% to 44%
depending on willingness-to-pay for health.
Conclusions
Cost-effectiveness
modeling can be used to determine the upper bound of financial
incentives used in pay-for-performance policies, although currently,
this approach is limited due to data requirements and modeling
assumptions. For tPA payments in acute ischemic stroke, our model-based
results suggest financial incentives leading to a 10-minute decrease in
door-to-needle time should be implemented but not exceed 18% to 44% of
current tPA payment. In general, the optimal level of financial
incentives will depend on willingness-to-pay for health and other
modeling assumptions around parameter uncertainty and the relationship
between quality improvements and long-run quality-adjusted life
expectancy and costs.
Footnotes
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