The strategy of using financial incentives to improve quality and lower costs is firmly embedded in the Affordable Care Act and the hospital value-based purchasing program launched nationwide in October 2012. The Affordable Care Act not only stiffens penalties for hospitals with high readmission rates but also uses risk-standardized 30-day mortality rates (RSMRs) for patients diagnosed with pneumonia, congestive heart failure, and acute myocardial infarction as a criterion for rewarding or penalizing hospitals. As currently designed, these incentives set a new benchmark for hospital quality and functionally establish a 30-day “warranty period” during which hospitals and physicians are held accountable for patient outcome.1 However, 2 questions are worth asking: (1) are RSMRs an appropriate measure of hospital quality; and (2) does linkage of incentives to RSMRs for the 3 highest-volume hospital conditions increase the potential for early misuse or overuse of hospice or palliative care measures for patients whose risk of death is higher than expected but by no means certain?
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