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Pay-for-Performance: A Decision Guide for Purchasers. Guide Prepared for: Agency for HealthCare Research and Quality U.S. Department of Health and Human Services Prepared by: R. Adams Dudley, M.D., M.B.A. University of California San Francisco Meredith B. Rosenthal, Ph.D. - PowerPoint PPT Presentation
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Pay-for-Performance: A Decision Guide for Purchasers
Guide Prepared for:
Agency for HealthCare Research and QualityU.S. Department of Health and Human Services
Prepared by:R. Adams Dudley, M.D., M.B.A.University of California San FranciscoMeredith B. Rosenthal, Ph.D.Harvard School of Public Health
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Pay for Performance:A Decision Guide for Purchasers
Electronic Copy of Guide and other AHRQ P4P Resources: Electronic Copy of Guide and other AHRQ P4P Resources: http://www.ahrq.gov/qual/pay4per.htm
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Overview
Not a users manual: too little data Addresses:
Developing an overall strategy Incentive design and measures selectionImplementationEvaluation and revision
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Is Our Community Ready?
Do we know what we are trying to accomplish?
Do we have enough influence? Are the providers ready?
5
Strategic Issues: Getting Started
Voluntary vs. mandatory: Voluntary: easier, may only attract high-
performing providersMandatory (i.e., written into all contracts):
creates uniform incentives, but may need high market share
Bonus program is in between: “mandatory”, but providers are free to ignore it
Phasing in: start with volunteers, or “pay for participation”/“pay for reporting”
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Strategic Issues: Getting Started
Which providers to target?: Hospitals and/or physicians Large vs. individual/small group
Contribution of hospitals vs. physicians to quality and cost varies from region to region
Measurement issues favor larger groups but incentives may be stronger for individuals
System view of quality improvement suggests higher level
Choose the provider target for which you can get the biggest bang for your buck
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Increasing Inclusion of Specialists and Hospitals in Pay-for-Performance
96%
46%
32%
100%
75%
50%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
PCP Specialists Hospitals
2003 2006
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Choosing Measures
National measure sets should be considered firstTestedAcceptedAlready being collected
Some sources: AHRQ (Inpatient Quality Indicators), National Quality Forum, Hospital Quality Alliance, Ambulatory Care Quality Alliance, NCQA, Leapfrog Group
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Incentive Design Challenges
All P4P programs are not the same Design choices matter First critical question is orientation:
Quality improvement across all providers, patients?
Rewards for the best only? E.g., Premier Inc./CMS demonstration
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Explicitly or Implicitly Rewarding Quality Improvement
P4P programs that reward top group (e.g., 20%) or set a benchmark for reward that all must meet do not uniformly encourage improvement
These features should result in more QI:Rewarding improvement explicitly (i.e.
change rather than/in addition to level)Multiple levels of rewards (partial credit)Payments tied to each patient treated well
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Case Example: Hudson Health Plan: Rewarding Quality Diabetes Management
Measure Reward
Blood pressure $15 for screening and $35 for BP<130/80 or $20 for <140/90 or $15 for ≥10 mmHg decrease in one and goal in the other
Smoking cessation counseling $15
A1C testing and control $15 for screening and $35 for A1C<7 or $20 for A1C<9 or $15 for a 1% or more reduction
LDL-C testing and control $15 for screening and $35 for LDL<100 or $20 for LDL <130 or $15 for evidence of drug tx
Documentation of albuminuria; ACE/ARB treatment if positive
$15 for screening and $35 for negative test, evidence of drug tx, evidence of contraindication, or nephrology consult
Retinal exam $15 for exam with documentation of result
Pneumococcal vaccine $10
Flu shot $10
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Key Design Issues: How Much Money?
To be effective, bonus should be commensurate with cost of effort
Little good information about what it takes to reach quality targets
Most P4P programs for physicians 5-10% of associated fees; hospitals 1-2%
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Planning Ahead for Evaluation
You spent all that time and money…shouldn’t you assess what you accomplished?
Aspects of implementation can facilitate evaluation Collecting data during a measurement (i.e. non-
payment) year will allow before/after comparison Implementing P4P for some providers before
others may create a natural comparison group
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What Types of Effects to Look For
Data collection should not only track intended consequences but also monitor potential side effects:Patient selection/dumping (changes in
case-mix, excessive switching)Diversion of attention away from other
important aspects of careWidening gaps in performance between
best and worst
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Summary
Pay-for-performance can facilitate improved patient care, cost-efficiency
Best practices still unknown Careful matching of goals and
mechanisms will most likely lead to best results
In light of uncertainties about design, evaluation is key