Monday, October 24, 2016: 10:30 AM
Bayshore Ballroom Salon F, Lobby Level (Westin Bayshore Vancouver)

Ankur Pandya, PhD1, Djora Soeteman, PhD1, Ajay Gupta, MD2, Hooman Kamel, MD2 and Meredith Rosenthal, PhD1, (1)Harvard T.H. Chan School of Public Health, Boston, MA, (2)Weill Cornell Medicine, New York, NY

Purpose: Healthcare payers in the U.S. are increasingly tying provider payments to quality or value using pay-for-performance (P4P) policies. Cost-effectiveness analysis (CEA) quantifies value in healthcare but is not currently used to design P4P policies. We used a stroke simulation model to demonstrate how value-based acute ischemic stroke (AIS) payment adjustments (P4P incentives) could be determined using CEA.

Methods: We used a previously-published AIS simulation model to calculate the difference in population-level net monetary benefit (NMB, willingness-to-pay of $100,000/quality-adjusted life year [QALY]) accrued under current Medicare policy (stroke payment not adjusted for performance) compared to various hypothetical P4P scenarios. Performance measurement was based on time-to-thrombolytic treatment with tissue-type plasminogen activator (tPA). tPA within 0-3 hours of stroke onset leads to superior acute outcomes quantified by the modified Rankin Scale (mRS). In the model, time-to-tPA influenced acute mRS outcomes; discounted lifetime QALYs and stroke-related costs (payer perspective) were projected based on mRS outcomes. Time-to-tPA was modeled by adding time from: 1) stroke onset to hospital arrival; to 2) hospital arrival to tPA (“door-to-needle”). In P4P scenarios, we modeled door-to-needle time reductions of 0-30 minutes (range based on the national Get With The Guidelines initiative average 10 minute reduction) and tPA payment (unadjusted payment=$6,270) increases of 0-50% for timely (cost-effective) treatment.

Results: Without performance-based payment (i.e, current payment), tPA versus no tPA had incremental cost-effectiveness ratios of: $14,300/QALY in the 0-3 hour treatment window; $27,100/QALY in the 3-4.5 hour window; and was dominated in the 4.5-6 hour window. Compared to current payment, equivalent population-level NMB was achieved in P4P scenarios with 10 minute door-to-needle time reductions (6,392 more AIS cases/year in the 0-3 hour window) incentivized by increasing tPA payment by as much as: 10.5% for 0-4.5 hours; 12% for 0-3 hours and 6% for 3-4.5 hours; or 13.75% for 0-3 hours only. Population-level NMB differences between current and P4P payment scenarios depended on the sizes of performance improvements and payment incentives (Figure).    

Conclusions: Determining the optimal size of financial incentives used in P4P is an important challenge facing policy developers who seek to improve the value of healthcare delivered in the U.S. Value-based AIS payment adjustments can be set using CEA and a NMB framework that could be generalized to other quality measures across health conditions.