Productivity bonuses for hospitalists may decrease high-value care culture

Researchers surveyed hospitalists from 12 California hospitals about their institutions' culture of value-based decision making and found an association between high-value culture scores and how hospitalists were paid.


Hospitalists who are paid salary plus productivity adjustments reported lower measures of high-value care culture at their institutions than those receiving salary or wages alone, a recent study found.

From January through June 2016, researchers conducted a cross-sectional survey of 255 internal medicine hospitalists (mean age, 39 years; 50.6% female) from 12 hospitals in California with varying CMS value-based purchasing scores: four university centers (n=147; 57.6%), four community centers (n=85; 33.3%), and four safety-net centers (n=23; 9.0%). Participants completed the High-Value Care Culture Survey (HVCCS), a validated survey that measures the culture of value-based decision making among frontline clinicians. The survey includes four domains: 1) leadership and health system messaging, 2) data transparency and access, 3) comfort with cost conversations, and 4) blame-free environment. Scores were standardized to a scale of 0 to 100 points for each of the four domains and were averaged for an overall score.

The researchers tested the association between high-value culture scores and hospitalist productivity payments, adjusting for physician- and hospital-level characteristics, including age, gender, and training track. Hospital type and size were considered random effects. Results were published online on Oct. 31 by the Journal of Hospital Medicine.

Overall, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) reported payment with salary plus productivity adjustments. Twelve (4.7%) hospitalists reported being paid with salary plus quality or value adjustments. About half (n=123; 48.6%) of participants agreed that funding for their group depended on the volume of services they delivered. Community-based hospitalists reported higher rates of reimbursement with salary plus productivity (n=47; 32.0%), compared to hospitalists at university centers (n=24; 28.2%) and safety-net centers (n=6; 26.1%).

For about two-thirds of HVCCS items, more than 30% of hospitalists overall agreed or strongly agreed that components of low-value care culture were present at their institutions. In particular, more than 80% of hospitalists reported low transparency and limited access to data. In multilevel regression modeling, hospitalists who reported payment with salary plus productivity adjustments (β=−6.2; 95% CI, −9.9 to −2.5) had lower mean HVCCS scores than those who reported payment with only salary or wages (P<0.01). Hospitalists who reported reimbursement with salary plus productivity adjustments also had lower scores in the domains of leadership and health system messaging (β=−4.9; 95% CI, −9.3 to −0.6) and data transparency and access (β=−10.7; 95% CI, −16.7 to −4.6).

The six-point change difference with salary plus productivity adjustments would correspond with a hospital moving from the top to the median quartile of HVCCS score, representing a significant change in performance, the study authors said. There was no significant difference, however, associated with receiving salary with value incentives (although this result may be due to a relatively small sample size), they added.

Limitations of the study include its small subgroup sample size and the lack of a gold-standard measurement of high-value care, the authors noted. “This study is also cross-sectional and may benefit from the further evaluation of organizational culture over time and across other settings,” they wrote.