L. H. Nicholas1,2, D. Segev2 1Johns Hopkins University School Of Public Health,Health Policy & Management,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA
Introduction: The Center for Medicare and Medicaid Services (CMS) increasingly uses its role as one of the largest healthcare payers to influence quality of care. Despite good intentions, policies designed to purchase high-quality care may have unintended consequences. In 2007, CMS instituted aggressive Conditions of Participation (COP) for Transplant Centers, which flag transplant programs with worse than expected patient or graft survival for reviews that can be time-consuming and have major financial consequences; CMS can require low-performing centers to stop treating Medicare and Medicaid patients or enter into a Systems Improvement Agreement limiting the scope of transplant programs. It is unknown whether flagging within a particular organ impacts the volume or quality of transplants of non-flagged organs.
Methods: We use data from the Scientific Registry of Transplant Recipients from 2004 – 2011 to study the intended and unintended consequences of CMS flagging for kidney and liver transplants, the most commonly transplanted organs, on other transplant programs within a center. We used difference-in-differences regression models to compare outcomes at 130 transplant centers that were versus were not flagged (or informed of poor performance) before and after COP implementation. Prior to the COP, hospitals received regular performance report cards but there were no sanctions against poor performers. This approach allows us to separate transplant center’s response to the threat of CMS sanctions from any changes in behavior that are driven by information about quality of care they are currently providing.
Results: 69 centers were flagged or notified of underperformance for kidney transplant and 43 for liver transplant at least once during the study period. Simply receiving information about performance was not related to statistically significant changes in volume for either the low-performing organ or other programs within a transplant center. However, programs flagged for poor performance in the COP period reduced volume for the flagged organ (54 fewer transplants per year after the second kidney flag, p < 0.01; 18 fewer transplants after the second liver flag, p < 0.10). Transplant centers also reduced lung transplant volume following flags for both kidney (-12, p < 0.10 for first flag, -14, p < 0.01 for second flag) and liver transplant (-20, p < 0.05 for first flag, -5.3 for second flag).
Conclusion: Transplant centers respond to the threat of CMS sanctions by reducing transplant volume for organ programs with and without potential quality programs. Reduced access to transplant across organ types may be an unintended consequence of CMS efforts to improve the quality of transplant care.