Want  to simultaneously improve the quality, cost-benefit and access to care?  This can only be accomplished if health care is less fractionated, the incentives are aligned and someone is measuring and managing--in other words, pay for performance (P4P).

No, I am not advocating cookbook medicine or big brother. What I am advocating, however, is patient-centric data, its translation into information, and gently, unobtrusive feedback to practitioners at the point of service with the patient, a longitudinal perspective, care coordination, prevention, illness care and follow-through where there are no barriers to appropriate access, tests and treatments.

Pay-for-Performance (P4P) - Not!

 P4P does not work(or does not work as intended), when...

•          The individuals responsible proximate to the care are not "causally related to the specific measured outcomes or goals and costs of care attributed to those very processes.....That is, [they] are so far removed from the carrot, they could care less. The authors augur for it 'trickling down.'" [Ed Comment- You've got to be kidding me! Which outcomes? Which attributable costs? Who might those practitioners be?]

•          "The incentives are paltry--that is they are insufficient to get or keep the practitioner's interest.       

◦           Beware the 'chicken and egg problem': "Upping the ante may be difficult until there is proof that P4P really works, which may not be forthcoming as long as incentives are too low."

•          The data--the "performance reporting requirements are (or are perceived to be) too cumbersome and costly." This adds insult to injury regarding the aforementioned meager incentives.

•          However, in some cases, the "rewards are high enough to make a difference, but the lower performing providers are put on a vicious circle of lower payments and resulting lower ability to invest in quality. They, and their patients, are 'left behind.'"

•          The new quality metrics that the administration wants (read: imposeslike 'cookbook medicine'), inevitably raisescosts in targeted disease areas.  This can counteract cost savings or foci of health improvements painstakingly garnered elsewhere.

•          "P4P providers select the 'better risks,' shifting the more 'problematic' patients (and associated costs) to other parts of the healthcare provider system. Costs crop up in other parts of the system – an effect also known as 'squeezing the balloon.'"

In summary, to have effective incentives the following is absolutely necessary:

•          The financial rewards must be meaningful enough to "get and keep the practitioner's attention." 

•          The incentive programs' goals and objectives are to "foster best, most cost-effective, salutary practices of medicine.  " The cause and the effect? Improve patient satisfaction and attenuate if not reduce the relative cost of care."

Reference:

[See Healthcare Frontiers, originally publication, February 06, 2012]

As anyone can see, the 'devil's in the details': obstacles include but are not limited to patient attribution, the practitioner "team," financial realities of the patient including cost-sharing and the ability to construct acuity-adjusted episodes of care and the 'gain and maintain' the interest or attention issues mentioned above.

Pay for performance did not reduce 30-day mortality more than hospital quality reporting alone. What does this mean for the redesign of health care delivery and are we on the right track?

For this six year study through the Premier Hospital Quality Incentive Demonstration researchers compared Medicare 30-day mortality rates for hospitals participating in the Premier HQID to a group of control hospitals participating in public reporting alone. Patients included in the study had acute myocardial infarction, congestive heart failure, pneumonia, or underwent coronary-artery bypass grafting between 2003 and 2009. The study found no difference in 30 day mortality rates between the two groups. (Sources: AHA News Now, http://ahanews.com, March 29, 2012, N Eng J Med, http://www.nejm.org, March 28, 2012)

Current Key References

 Worth reviewing is the January 23, 2013 edition of JAMA [Vol 309, No. 4] with 4 articles in Viewpoint and 3 Editorials that are relevant.  See, especially Williams MV. "A Requirement to Reduce ReadmissionsTake Care of the Patient, Not Just the Disease." JAMA. 2013;309(4):394-396. doi:10.1001/jama.2012.233964JAMA. 2013;309(4):394-396. doi:10.1001/jama.2012.233964By Mark V. Williams, MD  .." ." 

Also, an excellent reference, with stand-alone merit is:

"Quality Incentive Payment Systems: Promise and Problems" by Bonis, P. A. L. (free and with 37 references)

For further information, check out:

• Background/Summary Health care purchasers developed pay-for-performance programs as a way to "align incentives to providers in order to produce better health outcomes, which will likely decrease overall healthcare costs." This often involves return on investment (ROI) calculations as well as private and public report cards, disease or disease state management efforts, and point of contact patient care management and follow-through.


• The Leapfrog Group with support from the Agency for Health Care Research and Quality (AHCPR)  "define pay-for-performance broadly and include any type of performance-based provider payment arrangements, including those that target performance on cost or efficiency measures. Typically, pay-for-performance programs offer financial incentives to physicians and other healthcare providers who meet defined performance targets which tend to focus on quality, efficiency, or related areas ('AHRQ Resources')."