title: Access to coronary artery bypass graft surgery under pay for performance: evidence from the premier hospital quality incentive demonstration.
abstract: BACKGROUND
  Although pay for performance (P4P) has become common, many worry that P4P will lead providers to avoid offering surgical procedures to the sickest patients out of concern that poor outcomes will lead to financial penalties.
  
  
  RESULTS
  We used Medicare data to compare change in rates of coronary artery bypass graft surgery between 2002 to 2003 and 2008 to 2009 among patients with acute myocardial infarction (AMI) admitted to 126 hospitals participating in Medicare's Premier Hospital Quality Incentive Demonstration P4P program with patients in 848 control hospitals participating in public reporting through the Health Quality Alliance. We examined rates for all patients with AMI and those in the top decile of predicted mortality based on demographics, medical comorbidities, and AMI characteristics. We identified 91 393 patients admitted for AMI in Premier hospitals and 502 536 Medicare patients admitted for AMI in control hospitals. Coronary artery bypass graft surgery rates for patients with AMI in Premier decreased from 13.6% in 2002 to 2003 to 10.4% in 2008 to 2009; there was a comparable decrease in non-Premier hospitals (13.6%-10.6%; P value for comparison of changes between Premier and non-Premier, 0.67). Coronary artery bypass graft surgery rates for high-risk patients in Premier decreased from 8.4% in FY 2002 to 203 to 8.2% in 2008 to 2009. Patterns were similar in non-Premier hospitals (8.4%-8.3%; P value for comparison of changes between Premier and non-Premier, 0.82).
  
  
  CONCLUSIONS
  Our results show no evidence of a deleterious effect of P4P on access to coronary artery bypass graft surgery for high-risk patients with AMI. These results should be reassuring to those concerned about the potential negative effect of P4P on high-risk patients.
authors.affiliation: From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.). aepstein@hsph.harvard.edu.
authors.forename: Arnold M
authors.initials: AM
authors.lastname: Epstein
authors.affiliation: From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.).
authors.forename: Karen E
authors.initials: KE
authors.lastname: Joynt
authors.affiliation: From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.).
authors.forename: Ashish K
authors.initials: AK
authors.lastname: Jha
authors.affiliation: From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.).
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001026:Coronary Artery Bypass; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000601:surgery; D011787:Quality of Health Care; D012052:Reimbursement, Incentive / Q000706:statistics & numerical data*; D020379:Risk Adjustment; D014481:United States
keywords: coronary artery bypass grafting; pay for performance