Linking CEO Compensation to Organization-Wide Performance

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1 Linking CEO Compensation to Organization-Wide Performance Jean Chenoweth, Senior Vice President, Truven Health 100 Top Hospitals Programs David Foster, PhD, MPH, Chief Scientist, Truven Health Analytics Julie Shook, MPH, Director - Content, Truven Health Center for Healthcare Analytics October 2014 Overall Finding In this sample of and health systems, the total direct compensation of an organization s CEO is strongly associated with better performance of the entire organization. Executive Summary Hospital and health system chief executive officer (CEO) compensation is a controversial topic, as hospital boards and leadership focus on reform, rising costs, quality improvement, and increasing transparency. A frequently cited study on CEO compensation is a 2013 Harvard School of Public Health study by Karen Joynt and colleagues. 1 That study found that, while U.S. hospital CEO compensation was significantly associated with hospital teaching status, facility size, technology, and patient perception of care, it was not associated with quality, financial performance, or community value. The study used 2009 Centers for Medicare & Medicaid Services (CMS) Hospital Compare individual measures of performance and 2009 IRS Form 990 financial statements to analyze the relationship of CEO compensation with quality, financial performance, and community value. The purpose of hospital and health system CEO compensation is to incentivize high performance and ultimately reward an executive for effective implementation of the organization s mission, strategies, and goals factors that go beyond the CMS individual measures of performance. Researchers at the Truven Health Center for Healthcare Analytics hypothesized that CEO compensation should be associated with a score representing overall organization performance a composite of performance scores that encompasses measures of quality, operations, finance, patient perception of care, and more. To test the hypothesis, we performed regression analyses to determine whether a correlation exists between CEO direct compensation, reported by the 487 acute-care, general and 89 health systems that responded to the 2014 Integrated Health Strategies National Healthcare Leadership Compensation Survey, 2 and the hospital s or health system s composite scores on the 2014 Truven Health 100 Top Hospitals and 15 Top Health Systems balanced scorecards. 100 Top Hospitals Research

2 The 100 Top Hospitals and 15 Top Health Systems national balanced scorecards were selected based on academic validation, 21 years of field testing, correlation with Baldrige award winners 5-year rates of improvement and performance levels, and academic use for determining best governance practices. 3,4,5 The results showed highly significant correlations between CEO direct compensation and the composite score of all equally weighted hospital and health system national balanced scorecards. Further, the higher the performance levels increased on the balanced scorecard composite score, the higher compensation increased in consistent increments. Use of a Balanced Scorecard The concept of a balanced scorecard was developed by Norton and Kaplan at Harvard University 6 in the early 1990s to guide boards of public companies in objectively assessing organization-wide performance. The balanced scorecard approach enabled boards to effectively broaden the increasingly narrow focus on short-term financial results and delivered a range of key performance indicators associated with organizational goals. Those metrics provided a complete view of a CEO s success in executing all strategies and goals. In 1993, Truven Health Analytics developed the 100 Top Hospitals balanced scorecard a hospital-focused national balanced scorecard that applies public data to the balanced scorecard concept. Truven Health innovated further by creating a composite score of equally weighted scorecard measures and developing national benchmarks and medians. The objective was to measure the relative ability of hospital leadership to lead the organization to high, balanced performance across the areas of quality, efficiency, financial performance, and customer satisfaction. A hospital s 100 Top Hospitals composite score provides an unbiased assessment of its overall ranked performance, similar to external ranking of compensation comparables provided by compensation consultants. The composite score is calculated by adding together the national rank of performance for all individual measures considered. The sum of performance on all measures is then compared to the ranks of all national peers. Griffith and Alexander, University of Michigan, analyzed the 100 Top Hospitals databases and methods in 2002 and found that board use of a national balanced scorecard developed from publicly available data is valid. 3 In 2011, the U.S. National Institute of Standards and Technology selected the 100 Top Hospitals balanced scorecard to evaluate the relative performance of Baldrige award winners versus non-baldrige winning peers. 4 The results demonstrated that Baldrige award winners improved more than five times faster than peers on the national balanced scorecard over five consecutive years. Further, Baldrige award winners were two times more likely to be named Truven Health 100 Top Hospitals than non-winning peers within three years of selection for the award. 2 Linking CEO Compensation to Organization-Wide Performance

3 The 15 Top Health Systems national balanced scorecard uses the same methodologies as the 100 Top Hospitals study and aggregates member data into a system s total scores for comparison to other similar health systems. 7 The Analysis The hypothesis used for the CEO compensation research preliminary study was that total direct compensation (TDC) for a hospital s or health system s CEO is correlated with a composite score of the organization s balanced scorecard measures. The composite score of the 100 Top Hospitals or the 15 Top Health Systems national balanced scorecard was selected for use in the study. TDC was defined as total annual cash compensation plus the annualized value of long-term incentives. A hospital s composite score is the sum of the hospital s national rank on the nine equally weighted measures listed below. A health system s composite score is the sum of the health system s national rank on each of the same equally weighted measures, excluding the expense and profit metrics noted with asterisks: Risk-adjusted mortality Risk-adjusted complications Agency for Healthcare Research and Quality (AHRQ) patient safety measures CMS 30-day measures CMS Core Measures Severity-adjusted lengths of stay Expense per adjusted discharge* Profit from operations* CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Willingness to Recommend scores Five of the nine measures reflect various aspects of clinical quality inpatient outcomes, inpatient safety, post-discharge outcomes, and adherence to proxies for evidence-based medicine. Goals of the analysis were to use 2012 Integrated Healthcare Services survey data and the matching Truven Health 100 Top Hospitals composite scores to evaluate TDC at the system and, separately, hospital level, to determine the association between it and lowerperforming versus higher-performing organizations. Data Sources Truven Health 100 Top Hospitals study databases were used to assess hospital performance. The databases include: CMS MEDPAR data for federal fiscal years 2011 and 2012 CMS Hospital Compare data from 2013 for 30-day mortality and readmission rates, Core Measures, and HCAHPS Integrated Healthcare Services hospital-level data on total CEO compensation for Linking CEO Compensation to Organization-Wide Performance 3

4 Research Methods Integrated Healthcare Services contributed TDC data from 487 and 89 health systems from its leadership and compensation survey. Truven Health matched the survey data with the corresponding Top Hospitals and 15 Top Health Systems composite scores for overall organization performance on the national balanced scorecard, as well as the individual metrics. Financial data was not available for health systems. The initial analysis evaluated the association between TDC and the overall hospital or health system performance on the 100 Top Hospitals national balanced scorecard. At each level, the relevant composite performance score was used: Hospital level 100 Top Hospitals balanced scorecard composite score, including financial performance Health system level 15 Top Health Systems balanced scorecard, excluding financial performance The dependent variable of interest was total direct compensation, with independent, or predictor, variables comprised of various performance measures from the Top Hospitals study. The geometric mean of TDC was modeled against the following independent variables: Overall, or composite, 100 Top Hospital performance percentile score Mortality Complications Length of stay (LOS) AHRQ Patient Safety Indicator composite CMS Core Measures Adjusted inpatient expense per discharge Profitability CMS HCAHPS (patient impression of care provided and care setting) Subsequent analyses evaluated associations between various specific measures used in the 100 Top Hospitals or 15 Top Health Systems balanced scorecards and total compensation. We examined the distribution of by class for both 100 Top Hospitals and Integrated Healthcare Services organizations to determine that there would sufficient volume in each class, and all analyses were adjusted for standard 100 Top Hospitals class assignment, which provides stratification adjustments on bed size category and teaching status. (See Figure 1 for class assignment and distribution details.) 4 Linking CEO Compensation to Organization-Wide Performance

5 Figure 1: Percentage Distribution of Hospitals by 100 Top Hospitals Class n= Top Hospitals (2014) IHS Total Direct Compensation (n=hospital count) Percent Distribution n=82 n=75 n=112 n= Major teaching Teaching Large community Medium community Small community Top Hospitals Class Sources: Truven Health 100 Top Hospitals Study, 2014; Integrated Health Strategies National Healthcare Leadership Compensation Survey, 2014 To facilitate the analyses, SAS proc GLM was used to fit linear regression models, which would provide for the examination of associations between total direct compensation and various 100 Top Hospitals performance measures, while implementing adjustment for 100 Top Hospitals class assignments. Statistical significance was evaluated at an alpha level of Log transformation was completed as needed to ensure a more normal distribution of total direct compensation in accordance with the linear model assumptions. Duan s smearing technique 8 was used to retransform log total direct compensation back to the original units in an unbiased way. To evaluate whether there were differences between lower and higher performing organizations in terms of the association between performance and compensation, two separate models were also conducted one on lower performing organizations (in the lowest 50 percent of all /health systems) and the other on higher performing organizations (highest 50 percent). Linking CEO Compensation to Organization-Wide Performance 5

6 Results There were 487 and 89 hospital systems included in the study. Correlation results showed a value of 0.79 (p<0.0001) for overall 100 Top Hospitals performance and total direct compensation at the hospital level. At the system level, the correlation was 0.75 (p<0.0001). Specifically, we found that compensation increased by an average of 1.5 percent for each unit increase in 100 Top Hospital performance percentile. Performance at the hospital level was associated with an average increase in compensation of 1.1 percent per each unit increase in 15 Top Health Systems performance percentile. Figure 2: Percentage Change in TDC per Unit Increase in Percentile Performance of 100 Top Hospitals and 15 Top Health Systems Composite Measures 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% Hospital System Sources: Truven Health 100 Top Hospitals and Truven Health 15 Top Systems Studies, 2014; Integrated Health Strategies National Healthcare Leadership Compensation Survey, 2014 The analysis of individual components of the 100 Top Hospitals composite performance measure showed that profitability and expense per adjusted inpatient discharge were highly associated with compensation (p<0.0001) in a way that indicated higher compensation with better performance. Adjusted associations in the lowest- and highest-performing and health systems revealed little difference in compensation tied to performance. For the lowest 50 percent of, there was an increase in compensation of 2.2 percent per each unit increase in scorecard performance percentile. At the system level, the increase was 1.3 percent. For both the highest 50 percent of and health systems, there was an increase in compensation of 1.7 and 1.8 percent per each unit increase in scorecard performance percentile for hospital and health system, respectively. 6 Linking CEO Compensation to Organization-Wide Performance

7 Conclusions In this sample of and health systems, increased TDC is strongly associated with better performance of the organization. While the overall, or composite, 100 Top Hospitals performance score was directly and significantly associated with compensation, the examination of individual subcomponents of the 100 Top Hospitals composite showed a mixed result. Specifically, profitability and expenses per adjusted inpatient discharge showed associations with compensation. All of these results were statistically significant. A second study to further assess and validate the connection between CEO performance and compensation is planned by Truven Health, using the most current Form 990 tax returns and performance data of nearly 3,000 and 400 health systems. The results will be published in Study Limitations The results of this study are based on a limited sample of 487 acute-care, general and 89 health systems. While the sample is adjusted to reflect a national distribution of, replication of the result with a larger sample is desirable and underway. The results of this investigation are based on administrative, or claims, data. Such data do not contain much of the important clinical information that would improve the epidemiologic rigor of this type of study. The use of administrative data, however, does provide an efficient way to compare performance across many organizations, as is being done by CMS, AHRQ, and others. However, most experts agree that these types of data are not adequate for confirming the presence of causal association. In other words, these data and methods are sufficient for establishing the existence of associations, but not necessarily confirmatory for causal relationships. References 1 Joynt KE, et al. Compensations of chief executive officers at nonprofit US. JAMA Intern Med 2013; DOI: /jamainternmed National Healthcare Leadership and Compensation Survey 2014, Integrated Healthcare Services. Includes data on 175 executive positions and 39 manager positions from more than 1,350 facilities in the U.S. 3 Griffith and Alexander, University of Michigan. Comparison of Baldrige Award Applicants and Recipients With Peer Hospitals on a National Balanced Scorecard, National Institute of Standards and Technology (NIST) Brief, Comparison of Baldrige Award Applicants and Recipients with Peer Hospitals on a National Balanced Scorecard, October Prybil L, UK College of Public Health, Governance in Large Nonprofit Health Systems: Current Profile and Emerging Patterns, Kaplan RS, Norton DP. The Balanced Scorecard: Measures that Drive Performance. Harvard Business Review, Jan Feb Top Hospitals: Study Overview, Truven Health Analytics, 21st Edition, March 3, Duan N. Smearing Estimate: A Nonparametric Retransformation Method, Journal of the American Statistical Association, Vol., 78, No (Sept. 1983), pp Linking CEO Compensation to Organization-Wide Performance 7

8 About the 100 Top Hospitals Program The Truven Health Analytics annual 100 Top Hospitals program uses public data to recognize exhibiting the highest performance on a national balanced scorecard relative to peers. Because only public data is used in this study for transparency purposes, all are included. There is no application form, application fee, marketing fee, or any other fee for inclusion in the study. Study results and winner lists are highly anticipated each year and have been for two decades. The Truven Health study is unique in that it evaluates on a composite score reflecting performance across key indicators, including inpatient clinical care and 30-day outcomes, efficiency, financial stability, and patient perception of care. It compares only against similar facilities in terms of size and teaching status. FOR MORE INFORMATION Please contact the Truven Health Center for Healthcare Analytics at For more information on the 100 Top Hospitals program, visit 100top.com. ABOUT TRUVEN HEALTH ANALYTICS At Truven Health Analytics, we are dedicated to delivering the answers our clients need to improve healthcare quality and reduce costs. We are a healthcare analytics company with robust, widely respected data assets and advanced analytic expertise that have served the global healthcare industry for more than 30 years. These combine with our unique perspective from across the entire healthcare industry to give, clinicians, employers, health plans, government agencies, life sciences researchers, and policymakers the confidence they need to make the right decisions, right now, every time. With our healthcare-specific expertise and tools for managing complex and disparate data, we understand how to implement and integrate tailored analytics that drive improvement. Truven Health Analytics owns some of the most trusted brands in healthcare, such as Micromedex, ActionOI, 100 Top Hospitals, MarketScan, and Advantage Suite. Truven Health has its principal offices in Ann Arbor, Mich.; Chicago; and Denver. For more information, please visit truvenhealth.com. truvenhealth.com Truven Health Analytics Inc. All rights reserved. All other product names used herein are trademarks of their respective owners. TOP

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