title: Payer leverage and hospital compliance with a benchmark: a population-based observational study.
abstract: BACKGROUND
  Since 1976, Medicare has linked reimbursement for hospitals performing organ transplants to the attainment of certain benchmarks, including transplant volume. While Medicare is a stakeholder in all transplant services, its role in renal transplantation is likely greater, given its coverage of end-stage renal disease. Thus, Medicare's transplant experience allows us to examine the role of payer leverage in motivating hospital benchmark compliance.
  
  
  METHODS
  Nationally representative discharge data for kidney (n = 29,272), liver (n = 7,988), heart (n = 3,530), and lung (n = 1,880) transplants from the Nationwide Inpatient Sample (1993-2003) were employed. Logistic regression techniques with robust variance estimators were used to examine the relationship between hospital volume compliance and Medicare market share; generalized estimating equations were used to explore the association between patient-level operative mortality and hospital volume compliance.
  
  
  RESULTS
  Medicare's transplant market share varied by organ [57%, 28%, 27%, and 18% for kidney, lung, heart, and liver transplants, respectively (P < 0.001)]. Volume-based benchmark compliance varied by transplant type [85%, 75%, 44%, and 39% for kidney, liver, heart, and lung transplants, respectively (P < 0.001)], despite a lower odds of operative mortality at compliant hospitals. Adjusting for organ supply, high market leverage was independently associated with compliance at hospitals transplanting kidneys (OR, 143.00; 95% CI, 18.53-1103.49), hearts (OR, 2.84; 95% CI, 1.51-5.34), and lungs (OR, 3.24; 95% CI, 1.57-6.67).
  
  
  CONCLUSIONS
  These data highlight the influence of payer leverage-an important contextual factor in value-based purchasing initiatives. For uncommon diagnoses, these data suggest that at least 30% of a provider's patients might need to be "at risk" for an incentive to motivate compliance.
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, Michigan 48109-0330, USA. kinks@med.umich.edu <kinks@med.umich.edu>
authors.forename: John M
authors.initials: JM
authors.lastname: Hollingsworth
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Krein
authors.forename: David C
authors.initials: DC
authors.lastname: Miller
authors.forename: Sonya
authors.initials: S
authors.lastname: DeMonner
authors.forename: Brent K
authors.initials: BK
authors.lastname: Hollenbeck
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019985:Benchmarking / Q000379:methods*; D002648:Child; D016001:Confidence Intervals; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000331:legislation & jurisprudence / Q000592:standards*; D008875:Middle Aged; D019370:Observation; D016377:Organ Transplantation / Q000401:mortality / Q000592:standards* / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000191:economics*; D012052:Reimbursement, Incentive; D013503:Surgery Department, Hospital / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data*; D019737:Transplants / Q000145:classification / Q000706:statistics & numerical data; D014481:United States; D014600:Utilization Review