Paying for Performance Improvement in Quality and Outcomes of Cardiovascular Care: Challenges and Prospects

Abstract

Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with pay-for-performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so.

Keywords: alternative payment models; cardiovascular care; pay for performance; value-based purchasing.

Figure 1.

Timeline of federal efforts to improve quality of cardiovascular care. (A) Timeline for various value-based purchasing (VBP) programs divided by hospital-level (orange) and physician-level programs (green). The HRRP and HVBP were created after the ACA and will potentially be consolidated, with other federal hospital programs, into a single program in 2022. Prior physician-level programs such as PQRS, MU, and PVBM were consolidated into the QPP in 2019. The QPP has two main components, MIPS and APMs. (B) The two main APMs for cardiovascular care include ACOs and BPCI-A. ACA: Affordable Care Act; ACO: Accountable Care Organization; APM: Alternative Payment Model; BPCI: Bundled Payments for Care Improvement; BPCI-A: Bundled Payments for Care Improvement-Advanced; HRRP: Hospital Readmissions Reduction Program; HVBP: Hospital Value-Based Purchasing Program; MIPS: Merit-based Incentive Payment System; MU: Meaningful Use Program; PQRS: Physician Quality Reporting System; PVBM: Physician Value-Based Modifier Program; QPP: Quality Payment Program

Figure 2.

Diagram of the components within the Quality Payment Program (QPP). The QPP is composed of the Merit-Based Incentive Program (MIPS) and Alternative Payment Models (APMs). MIPS is the default program for clinicians and is composed of the following four elements (2020 weights reported): Quality 45%, Promoting Interoperability 25%, Cost 15%, Improvement Activities 15%. Clinicians can opt out of MIPs if they are enrolled in a qualifying APM; within cardiovascular care, this could mean either participating in an accountable care organization or being part of an organization that is participating in the Bundled Payments for Care Improvement-Advanced program.

Figure 3.

Challenges for improving quality, outcomes, and cost in cardiovascular care. The challenges facing the successful implementation of value-based, high-quality cardiovascular care include program efficacy, accuracy and equity, administrative burden, and data manipulation. BPCI: Bundled Payments for Care Improvement; HRRP: Hospital Readmissions Reduction Program; HVBP: Hospital Value-Based Purchasing Program; MSSP: Medicare Shared Savings Program; SDoH: social determinants of health

Figure 4.

Prospects for improving quality, outcomes, and cost in cardiovascular care. Encouraging prospects for the successful implementation of value-based, high-quality cardiovascular care include the incorporation of improved data science for improved risk adjustment, decreased administrative burden, and potential innovative care delivery models. SDoH: social determinants of health