Program Design and Implementation

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Arguably the most difficult aspect of any P4P program is generating measures that providers, payers, and patients agree on. Designing measures has been an arduous task. And although much effort has already been spent on developing current measures, criticisms are ongoing, and measures must be improved. First, the debate starts with what to measure: structure, process, or outcome. Some authors suggest alternatives, for example value (99) and efficiency (83). Horn (121) calls for a comprehensive data collection process that can accurately measure treatment variables which affect outcome as a prerequisite to P4P.  Lin (296) argues that only well-established measures should be utilized when linking reimbursement to guidelines. Currently however, most of P4P programs utilize process-based measures, like checking A1c every three months, for reimbursement. Although CMS has been a major player in developing measures, there are many other groups making recommendations for P4P programs, including the AAFP (262) and many others below in the "Specialities" section. Meanwhile, individual authors question aspects of developing measures, including Jha (50) process vs. outcome, Masoudi (70) using only one measure for determining quality care, Werner (294) national vs. local guidelines, and Franks (20) internal vs. external standards.  Finally, Landau (138) warns that all clinical guidelines have negative consequences, while Gandhi (304) cautions that we do not measure patient outcomes well in current clinical trials, and we must do a better job if we are to rate quality based on patient outcomes.

Others point out that multiple factors that may contribute to better implementation of and adherence to quality measures. For example: Armour (269) states bonuses directly to physicians will result in greater changes; Sinsky (141) provides an example of how information phrased to patients can vary their outcomes; Glickman (324) observed clinical guidelines to be more effective than administrative guidelines; and Vina (248) believes P4P will be more effective when it is one facet of a larger quality improvement project. 

Diagnostic error may also be tied to performance and quality measure development. A committee with the Institute of Medicine (IOM) determined in a recent report that nearly all patients will experience diagnostic error in their lifetime. The committee recommended "all health care organizations monitor their own diagnostic processes to identify, learn from, and reduce diagnostic errors and near misses" (328)

We realize that readers would like to know and read examples of current measures.  However, the list is quite extensive and decided the best way to provide readers a chance to review measures was to provide a link to the CMS measures. Within the link one can browse the measure by topic, and then read the description and rationale for many measures on the website:

 

CMS Guidelines: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Inst...

 

As early as 2008 there were more than 160 P4P programs in the United States each with their own set of measurements. Currently, there are no formal or consistent program requirements for implementing measures. In turn, many groups have implemented their own P4P program while others build yet another individual program. Each program uses unique measures in their approach to improve quality and/or reduce costs. The problem of multiple measures for multiple programs has made it difficult for physicians to participate in multiple programs simultaneously. States such as Minnesota have formed working groups of clinicians, insurers, purchasers, state government representatives, and quality experts to align core measures of quality in order to reduce bureaucratic barriers and enable clinicians to more easily participate in multiple programs simultaneously. Additionally, prominent third-party groups exist solely to grade, critique. and help develop current measures. This is not an exhaustive list, but groups include:

 

Bridges to Excellence

http://bridgestoexcellence.org/

Leapfrog

http://www.leapfroggroup.org/

AHRQ

http://www.pso.ahrq.gov/ , http://www.ahrq.gov/

AQA

http://www.ambulatoryqualityalliance.org/

IHA

http://www.iha.org/

NCQA

http://www.ncqa.org/

NQF

http://www.qualityforum.org/

AHIP

http://www.ahip.org/

 

The articles in this category represent a small fraction of the variability between programs, and have been selected here as they either are currently implementing a P4P program, or suggest means in which to do so. Amundson (16) analyzes HealthPartners in Minnesota and shows one example of a P4P program improving outcomes. Meanwhile, Mikta (129) argues that P4P could be utilized to increase recommended treatments like cardiac rehab, and Wojcik (167) provides an example of an outcome-based application by using P4P in depression treatment. Levin-Scherz (206) shows that the ability to collect and utilize data is key to the success of P4P programs. Pearlstein (299) reports a P4P program in Michigan that can terminate physicians if they do not meet certain performance measurements within five years. 

 


Evaluating Measures

Groups evaluating measures play a vital role in P4P program design. As programs across the country are beginning to produce data, it is imperative that we analyze that data and evaluate the P4P measures on a constant basis. Systematic reviews of Emergency medicine (168) and ambulatory care (169) were both published in 2008. Both authors compare current research with the validity of their assigned P4P measures. Reviews of this manner will likely be forthcoming across each specialty. Werner (315) provides an in depth analysis of the 5 primary P4P payment strategies, and Fonarow (313) reinforces that measures which provide hospital reimbursement should ensure desired outcomes. Additionally, Smith (57) points out a P4P program that may have reached a “ceiling effect” after four years of implementation.

 

Website Authors' Opinion

Designing and implementing measures which are agreeable to patients, providers, and insurers is likely the most difficult task to P4P. Furthermore, it will be vital to the success of P4P to then get consensus amongst numerous P4P programs so clinicians know exactly what measures to aim for to achieve bonuses. Then, reviews of P4P programs and their measures are vital for insuring that P4P programs are evidence-based, designed for quality improvement, and successful. If readers are still confused after reading this section thoroughly, do not worry, the authors of this site still struggle to wrap our thoughts numerous players and design features at play here. However, we would like to provide a list of design features below that we believe readers would benefit from greatly if they were faced with the challenging task of designing or implementing their own P4P program. Those debates are, but not limited to:

 

  • Medical and socioeconomic risk adjustment for clinic populations vs. no risk adjustment
  • Exception reporting based on clinical reasons (e.g. did not provide screening colonoscopy for 50 year old patient because he is in hospice for pancreatic cancer), vs. exception reporting for patient reasons (e.g. patient refuses colonoscopy and all other approved methods of screening), vs. exception reporting for systems reason (closest availability for colonoscopy is 300 miles and patient has no access to transportation), vs. no exceptions.
  • Use of performance measures targeting outcomes vs. processes vs. structural elements such as electronic health records. 
  • P4P bonuses for achieving an absolute target vs. reward for improvement over the previous year’s performance
  • Inclusion of ‘invisible’ patients who have never been seen in the clinic but who have been assigned to the clinic by their insurer vs. inclusion of only patients who have established a bona-fide physician-patient relationship
  • Additional reimbursement on a per-patient-per-month basis to finance outreach to ‘invisible’ patients or those who come to clinic infrequently vs. inclusion of those patients without additional clinic financing
  • All-or-nothing bonuses for entire patient populations vs. patient by patient bonuses
  • Inclusion of the entire clinic population in one insurer’s P4P program vs. inclusion of only one insurer’s patients in that insurer’s P4P program
  • Data collected by clinicians vs. data collected by P4P program (typically low-quality data extracted from billing data)
  • P4P bonuses in addition to full fee-for-service payments vs. P4P bonuses paid from pooled moneys withheld from fee-for-service payments
  • P4P bonus is new money vs. “withhold”
  • Clinical quality performance measures approved by the Centers for Medicare and Medicaid (CMS) vs. the use of independent measures designed by the insurers themselves
  • Choosing to provide greater rewards for modest improvements in sicker patients vs. greater rewards for achieving optimal care of healthier patients.

 

 

 

Program Design and Implementation Literature

Key Articles: 169, 262, 282, 316, 345, 351, 383, 408, 434

 

(16) Amundson G. Minnesota at the Forefront for Recognizing and Rewarding Quality Care. Metro Doctors. Mar/Apr 2006.

Summary:

  • Offers an overview of P4P, specifically with HealthPartners in Minnesota.
  • Reviews measureable outcomes that have worked for HealthPartners P4P programs.

Significance to Literature:

Example of a P4P program with improving outcomes.

 

(20) Franks A, et al. Trust, standards, and healthcare quality: a case of babies and bathwater? Journal of the Royal Society of Medicine. 2006: 98 112-114.

PMID: 16508047

Summary:

  • Internal quality improvement mechanisms must combine with external standards from government policy to improve patient care.

Significance to Literature:

Introduces the use of internal and external quality improvement mechanisms.

 

 

(50) Jha AK. Measuring Hospital Quality. JAMA. Editorial. 2006: 296(1) 95-97.

PMID: 16820553

Summary:

  • Editorial on Bradley et. al Hospital Quality for Acute MI article.
  • Focuses on hospital quality measures, process vs. outcome based.
  • Provides two main faults of each measurement practice, both need improvement.
  • Other aspects of hospital care should also be measured.

Significance to Literature:

Offers insight into common hospital-based measures used in today’s P4P.

 

(57) Smith S. 2007 quality scores stall. Minnesota Medical Association: Quality review. Winter, 2008.

Link: http://www.mmaonline.net/Portals/mma/Publications/QualityReview/MMAQuali...

Summary:

  • In 2007, outcome scores did not increase in Minnesota for the first time in 4 years.
  • Thought to be because of increasing numbers of participating physicians; results no longer reflect only the most advanced practices.
  • Thought to be because of possible ceiling effect. “Lots of groups have done the easy things to improve quality.”

Significance to Literature:

Statewide report of sustained P4P over four years with possible ceiling effect.

 

 

(70) Masoudi FA. Measuring the Quality of Primary PCI for ST-segment Elevation Myocardial Infarction. JAMA. Editorial. 2007: 298(23). 2790-2791.

PMID: 18165675

Summary:

  • Editorial argues against using just one quality measurement.
  • Measuring quality must account for factors like patient selection and ultimate outcomes.

Significance to Literature:

Editorial suggesting that one quality measurement for PCI may be insufficient as an overall quality marker.

 

 

(83) Terry K. Is P4P getting tougher? Medical Economics. July 20, 2007.

Summary:

  • Article summarizes a new P4P plan in California by IHA which measures risk adjusted efficiency as an incentive.
  • This new drive for standards comes from an inability to get quicker results, payers are getting impatient.
  • In contrast, the AMA expresses that the goal of P4P is not to save money, but offer better care.

Significance to Literature:

Is measuring efficiency appropriate?

 

 

(99) Smoldt RK, Cortese DA. Pay-for-Performance or Pay for Value? Mayo Clinic Proceedings. 2007: 82(2) 210-213.

PMID: 17290730

Summary:

  • Offers a formula for measuring value (value ratio), and an approach to paying for value.
  • Argues that our system needs a larger change than “piecemeal approaches.”
  • Argues for need to measure patient experience.
  • Proposes a new “pay for value” structure.

Significance to Literature:

Recognizes a need for formal measurement of value.

 

 

(121) Horn S. Performance Measures and Clinical Outcomes. JAMA. 2006: 296(22) 2731-2732.

PMID: 17164460

Summary:

  • Response to Werner and Bradlow(120).
  • Asks why should clinicians and health care centers be required to collect and submit data that does not support outcomes.
  • Suggests a new avenue for research called "practice-based evidence for clinical practice improvement."
  • A comprehensive data collection process that accounts for patient and treatment variables that affect outcomes.
  • Author acknowledges some inherent limitations.
  • Quality-of-care process measures must accurately reflect better outcomes.

Significance to Literature:

Offers a more comprehensive approach to data collection for developing stronger performance measures.

 

(129) Mikta M. Groups Publish Performance Measures Aimed at Boosting Cardiac Rehab Referrals. JAMA. 2007: 298(18) 2126-2128.

PMID: 18000191

Summary:

  • Less than 30% of eligible candidates for cardiac rehabilitation receive it.
  • Some are hoping that new performance guidelines will raise that number.
  • However, many barriers to cardiac rehabilitation include high cost and staffing needs.

Significance to Literature:

Performance measures can increase the use of certain treatment options, but barriers may still remain.

 

 

(138) Landau WM. Pertinacious Prescription of Practice Paradigms: The Ethical Burden of Coercive Clinical Guidelines. Current Neurology and Neuroscience Reports. 2007: 7 355-358.

PMID: 17764623

Summary:

  • Describes current neurological disease guidelines.
  • Author tries to assess how those guidelines were reached, and how they should be formed in the future.
  • Touches on the ethics of guideline development and implementation.

Significance to Literature:

Clinical guidelines can have negative consequences if inappropriately developed and implemented.

 

(141) Sinsky CA, Foreman-Hoffman V, Cram P. The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs. Journal of General Internal Medicine. 2007: 23(2) 164-168.

PMID: 18163191

Summary:

  • Study demonstrates that osteoporosis treatment compliance of both physician and patient is higher when data is presented as a relative risk, and not absolute risk.
  • This is important to consider as P4P is attempting to link compliance to reimbursement.
  • Study also found that patients become less and less likely to be compliant with prescription drugs as out-of-pocket expenses increase.

Significance to Literature:

Thinking about disease risk in absolute vs. relative terms and out-of-pocket costs of interventions to patients play major roles in determining whether patients and providers follow CPGs.

 

(167) Wojcik J. Coalition tests program to treat depression. Business Insurance. 2008: 42(22).

Link: http://www.businessinsurance.com/cgi-bin/article.pl?articleId=25047

Summary:

  • Bridges to Excellence launched a P4P program in Minnesota to treat depression.
  • The program will use the PHQ-9 to assess depression levels.
  • Doctors will receive $100 per patient for significant score reduction over 12 months.
  • This is the second time in the United States a P4P program for depression has been tried; the first was in Kansas City from 2000-2005.

Significance to Literature:

First outcome-based application of P4P for depression.

 

(168) Glickman SW, Schulman KA, Peterson ED, Hocker MB, Cairns CB. Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine. Annals of Emergency Medicine. 2008: 51(5) 622-631.

PMID: 18358566

Summary:

  • Article reviews the 9 emergency care performance metrics and grades them based on the American College of Cardiology and American Heart Association criteria for selection of performance measures to improve quality.
  • 5 of the 9 emergency measures meet all four of the criteria.
  • Authors suggest 2 new performance measures that should be used.
  • Quality improvement initiatives in emergency medicine would benefit greatly from large research networks.

Significance to Literature:

Overview and evaluation of the P4P measures in Emergency medicine.

 

 

Key Article

(169) Brantes FD, Wickland PS, Williams JP. The Value of Ambulatory Care Measures: A review of Clinical and Financial Impact from an Employer/Payer Perspective. The American Journal of Managed Care. 2008:14(6) 360-368.

PMID: 18554074

Summary:

  • Economic and clinical literature review of 62 quality metrics used in primary care P4P.
  • Of the top 20 metrics based on clinical and economic support, 16 were found to be cost-saving in the short-term.
  • Many primary care measures may have little clinical evidence beyond expert opinion.

Significance to Literature:

Systematic clinical and economic evaluation of 62 ambulatory care measures.

 

(299) Pearlstein S. Not What the Doctor Ordered? Part 1 and 2. The Washington Post. January 28, 2009.

Link: http://www.washingtonpost.com/wp-dyn/content/story/2009/01/27/ST20090127...

Summary:

Newspaper article discusses a new P4P program in Michigan that has many worried about goals of cost cutting benchmarks.

Reportedly, doctors can be terminated if they are unable to meet performance measures within five years.

Significance to Literature:

If P4P is used as means of cost control, there will be another set of challenges to address.

 

(206) Levin-Scherz J, DeVita N, Timbie J. Impact of Pay-for-Performance Contracts and Network Registry on Diabetes and Asthma HEDIS Measures in an Integrated Delivery Network. Medical Care Research Review. 2006: 63 14S-28S.

PMID: 16688922

Summary:

  • Authors summarize implementation and results of a P4P by Partners Community HealthCare Inc. (PCHI).
  • PCHI used a registry and claims data to provide incentives for quality care with diabetics and asthma patients.
  • PCHI reported substantial improvements in care from 2001-2003 in their asthmatics and diabetics.
  • Authors acknowledge the drawbacks to using claims data for measuring progress.

Significance to Literature:

The ability to collect and utilize data was key to PCHI’s P4P program through 2003.

 

(247) Brantes FSd. D’Andrea G. Physicians Respond to Pay-for-Performance Incentives: Larger Incentives Yield Greater Participation. The American Journal of Managed Care. 2009: 15(5) 305-310.

PMID: 19435398

Summary:

  • Authored by the CEO of Bridges to Excellence, the company that designed the program studied in the paper.
  • Study of data from Bridges to Excellence looking to determine the extent to which the size of the financial incentive influences physician participation.
  • Physicians increase participation in a linear fashion as the potential reward increases.
  • Physicians were more willing to participate sooner if incentives were individual rather than group incentives.

Significance to Literature:

The greater the reward, the more likely physicians will be to participate in P4P programs.

 

 

(248) Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT. Relationship Between Organizational Factors and Performance Among Pay-for-Performance Hospitals. Journal of General Internal Medicine. 2009: 24(7) 833-840.

PMID: 19415390

Summary:

  • Study aimed to find the key organizational factors associated with higher performance by interviewing executives in hospital administration.
  • Top performing hospitals were more likely to utilize clinical pathways for treatments, multidisciplinary teams, order sets for treatment, and computer physician order entry.
  • Top performing hospitals were also more likely to have adequate human resources for quality improvement projects and an organizational culture which promoted quality improvement.

Significance to Literature:

P4P is most likely to be successful when implemented as part of a larger quality improvement initiative.

 

Key Article

(262) Pay-For-Performance. AAFP position paper. August 29, 2005.

Link: http://www.aafp.org/online/en/home/policy/policies/p/payforperformance.html

Summary:

  • Summarizes the American Academy of Family Physicians (AAFP) stance on experimentation of physician payment methodologies, specifically in designing P4P programs.
  • The central purpose of all P4P programs must be to improve the quality of patient care and clinical outcomes.
  • Lists 14 guidelines for the development and implementation of P4P programs that the AAFP will support.

Significance to Literature:

AAFP position paper provides detailed criteria for P4P programs they would support.

 

 

(268) Young GJ, et al. Effects of Paying Physicians Based on their Relative Performance for Quality. Journal of General Internal Medicine. 2007: 22 872-876.

PMID: 17443360

Summary:

  • Retrospective analysis of an incentive program in which physicians had a financial risk; they could gain or lose income.
  • Study took place 3 years pre-incentive and 3 years post-incentive allowing the authors to estimate practice pattern changes over time.
  • 5% of all PCP’s salaries were withheld and placed in an incentive pool that was then redistributed according to a sliding scale of relative performance in clinical quality, patient satisfaction, and practice efficiency.
  • There was no difference in pre and post intervention trends as all areas were improving at the same rate, with one exception: there was a modest 1 time improvement in physician adherence for diabetic eye exams.  

Significance to Literature:

Study demonstrates only a modest effect in improving provider adherence to quality measures.

 

(269) Armour BS, et al. The Influence of Year-end Bonuses on Colorectal Cancer Screening. The American Journal of Managed Care. 2004: 10(9) 617-624.

PMID: 15515994

Summary:

  • Retrospective study using managed care plan claims from 2000 and 2001 which sought to examine explicit financial incentives to improve colorectal screenings in patients 50 years or older.
  • A $10,000 increase in income raises the probability of flexible sigmoidoscopy or colonoscopy screening approximately 2%.
  • Bonuses are more effective when targeted to individual physicians as opposed to a physician group.

Significance to Literature:

Cash bonuses to individual physicians can modestly increase screening of commercially insured patients.

 

(294) Werner RM, McNutt R. A New Strategy to Improve Quality: Rewarding Actions Rather Than Measures. JAMA. Commentaries. 2009: 301(13) 1375-1377.

PMID: 19336714

Summary:

  • Thus far, the measures thought to predict quality have proved to make little progress toward the quality improvement goal.
  • Local problems should not be addressed by a national solution. QI initiatives should be tied to local actions and local results, rather than national norms.
  • The focus of QI programs should be on improving rather than measuring the quality of care. This would help to focus a collaborative effort to identify solutions and provide on-going assessment.

Significance to Literature:

Collaborative and local approaches to QI should be utilized to improve quality of care.

 

 

(296) Lin KW, Slawson DC. Identifying and Using Good Practice Guidelines. American Family Physician Special Article. 2009: 79(12) 1-3.

Summary:

  • Defines 7 attributes of good practice guidelines:
    • Comprehensive, systematic evidence search
    • Strength of recommendation grading system
    • Recommendations based on patient-oriented rather than disease-oriented outcomes.
    • Transparent guideline development process
    • Conflicts of Interest identified
    • Prospectively validated
    • Offer flexibility in various clinical situations
  • Good guidelines should acknowledge situations where clinical decisions are not clear-cut and offer flexibility in these situations.

Significance to Literature:

It is essential to have well-established guidelines if we are to link reimbursement to guidelines.


 

(304) Gandhi GY, et al. Patient-Important Outcomes in Registered Diabetes Trials. JAMA. 2008: 299(21) 2543-2549.

PMID: 18523223

Summary:

  • In a sample of diabetes treatment randomized control trials, only 18% included death and quality of life as recorded primary outcomes.
  • 60% of trials used physiological or laboratory outcomes as primary outcomes.

Significance to Literature:

If the primary goal of P4P is to improve patient outcomes, shouldn’t that be measured more often in treatment trials.

 

(313) Fonarow GC, Peterson ED. Heart Failures Performance Measures and Outcomes: Real or Illusory Gains. JAMA. Commentary. 2009: 302(7) 792-794.

PMID: 19690314

Summary:

  • Outlines recent improvement in the four CMS heart failure performance measures.
  • However, these improvements have not led to decreases in 1-year readmission and mortality rates (outcomes).
  • "New measures should be required to more effectively quantify the quality of care provided to patients with heart failure."
  • Measures should be labeled provisional until they are well established to improve outcomes.

Significance to Literature:

 Measures which provide reimbursements for hospitals should ensure more desired outcomes.

 

(315) Werner RM, Dudley RA. Making The 'Pay' Matter In Pay-For-Performance: Implications For Payment Strategies: No one P4P payment type is best, and each offers different incentives for improving quality. Health Affairs. 2009: 28(5) 1498-1508.

PMID: 19738269

Summary:

  • Authors identified five primary P4P payment strategies including: relative rank, relative rank with penalties, target attainment, target attainment plus improvement, and percentage recommended.
  • Authors then used each strategy to calculate theoretical bonuses, and compared the advantages and disadvantages of each payment strategy
  • Results suggest that no one strategy is superior in achieving desired outcomes, however, authors suggest that payment schemes could progress and change over time allow for continual motivation and improvement.

Significance to Literature:

Overview of advantages and disadvantages of primary P4P payment strategies.

 

 

Key Article

(316) Foels T, Hewner S. Integrating Pay for Performance with Educational Strategies to Improve Diabetes Care. Population Health Management. 2009: 12 121-129.

PMID: 19534576

Summary:

  • Study aimed to assess improvement of diabetes care after P4P and inspirational support implementation
  • Assessed nine processed measures over 4.5 years, 
  • Results suggested that inspirational support and P4P produced an accelerated performance trajectory.
  • "Once providers are aware of gaps in their performance, they often are extremely interested in strategies that will help close the gaps."

Significance to Literature:

Positive P4P outcome with emphasis on teaching the clinician how to provide better care.

 

 

(324) Glickman SW, et al. Alternative Pay-for-Performance Scoring Methods: Implications for Quality Improvement and Patient Outcomes. Medical Care. 2009: 47(10) 1062-1068.

PMID: 19648833

Summary:

  • Analysis of AMI and heart failure measures comparing the mortality association between administrative versus clinical measure adherence.
  • Authors found clinical activities were associated with higher survival rates, rather than administrative process measures.
  • Therefore, it may be more beneficial to design incentives and spend limited financial resources on implementing measures that affect clinical activities.

Significance to Literature:

Measures more associated with better patient outcomes should be more targeted by quality improvement initiatives.

 

 

(328) McGlynn EA, McDonald KM, Cassel CK. Measurement Is Essential for Improving Diagnosis and Reducing Diagnostic Error: A Report From the Institute of Medicine. JAMA.2015;314(23):2501-2502. doi:10.1001/jama.2015.13453.

PMID: 26571126

Summary:

  • The Institute of Medicine (IOM) determined in a recent report that nearly all patients will experience diagnostic error in their lifetime.
  • The committee that issued the report identified five purposes for measuring diagnostic error:
    • Establish the magnitude and nature of the problem
    • Determine the causes and risks of diagnostic error
    • Evaluate the effectiveness of interventions
    • Assess skills in education and training
    • Establish accountability for diagnostic performance
  • The committee recommends “all health care organizations monitor their own diagnostic processes to identify, learn from, and reduce diagnostic errors and near misses.”
  • The committee also recommends the federal government creates funds and a strategy to research causes and consequences of diagnostic error.

Significance to Literature:

Overview of the IOM findings and recommendations for addressing diagnostic error.

 

 

(340) Baxter PE, et al. Leaders’ Experiences and Perceptions Implementing Activity-Based Funding and Pay-for-Performance Hospital Funding Models: A Systematic Review. Health Policy. 2015 Aug;119(8):1096-110. doi: 10.1016/j.healthpol.2015.05.003. Epub 2015 May 12.

Summary:

  • Systematic review of literature from 1982-2013 examining perspectives of health care leaders after implementing hospital funding reforms within Organisation for Economic Cooperation and Development (OECD) countries
  • Regardless of whether an activity-based funding or a pay-for-performance funding model was implemented, health care leaders described the complexity of the process in terms of:
    • Organizational commitment
    • Adequate infrastructure
    • Human, financial, and information technology resources
    • Personal commitment to quality care

Significance to Literature:

Systematic review of health care leader perspectives on implementing hospital funding models


 

 

(343) Shuaib W. Award Incentives to Improve Quality Care in Internal Medicine. Irish Journal of Medical Science. 2015 Jun;184(2):483-6. doi: 10.1007/s11845-014-1150-z. Epub 2014 Jun 4.

PMID: 24893851

Summary:

  • Development and implementation of internal medicine awards program
  • Pre-award survey was sent out electronically to faculty of internal medicine department to understand desire for employee recognition through an awards program
  • Five awards created included compassionate physician award, best service award, best mentor award, decade of excellence in teach award, and a scientific award for research
  • In a post-award survey, 78% of respondents stated award incentives would result in increased quality of personal performance

Significance to Literature:

Award incentives as chosen by peers may elevate personal performance and advance patient care quality.

 

 

Key Article

(345) Khullar D et al. How 10 Leading Health Systems Pay Their Doctors. Healthcare. 2015 Jun;3(2):60-2. doi: 10.1016/j.hjdsi.2014.11.004. Epub 2014 Dec 16.

PMID: 26179724

Summary:

  • Interviews with senior executives at ten leading health systems including: Kaiser, Mayo, Intermountain, Geisinger, Cleveland Clinic.
  • Analysis of healthcare organizations utilization of performance-based compensation
  • Performance-based pay more prevalent in primary care than in subspecialties
  • Most have less than 10% of pay tied to performance

Significance to Literature:

Models with many metrics and low at-risk compensation for each metric are often ineffective at reaching goals

 

 

(350) Bailit MH, Burns ME, Dyer MB. Implementing value-based physician compensation: advice from early adopters. Healthcare Finance Manager. 2015 Jul;69(7):40-7.

PMID: 26376508

Summary:

  • Recommendations from provider organizations  that have implemented value-based physician compensation include:
  • Link physician compensation to broader objectives of the organization
  • Use metrics physicians find credible and achievable
  • Ensure comprehension of all incentive measures and compensation formulas prior to implementation
  • Provide easily accessible, transparent, monthly performance data

Significance to Literature:

Summary of advice for provider organizations seeking physician compensation change from peers who have previously implemented value-based models

 

 

Key Article

(351) Greene J, Kurtzman ET, Hibbard JH, Overton V. Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians’ Perceptions. Annals of Family Medicine. 2015;13(3):235-241. doi:10.1370/afm.1779.

PMID: 25964401

Summary:

  • Examination of primary care provider perceptions of clinic-level quality incentives versus individual-level incentives.
  • Both in-depth interviews and online surveys were used to assess advantages and disadvantages of clinic vs individual level incentives.

Significance to Literature:

Most (73%) clinicians stated both clinic and individual-level incentives should be used in order to promote collaboration while still recognizing individual performance.

 

 

(354) Damberg CL, Elliott MN, Ewing BA. Pay-for-performance schemes that use patient and provider categories would reduce payment disparities. Health Affairs. 2015 Jan;34(1):134-42. doi: 10.1377/hlthaff.2014.0386.

PMID: 25561654

Summary:

  • Providers caring for a disproportionately disadvantaged patient population often have lower quality measures and decreased compensation
  • Authors proposed and evaluated an alternative performance-based payment model by “post-adjusting” provider payments based on patient characteristics such as income, race/ethnicity, and region.
  • Clinics were segmented into “disadvantaged, intermediate, and advantaged provider organizations” according to the populations they served.
  • Post-adjustment strategy doubled payments to disadvantaged provider groups and reduced payment disparities

Significance to Literature:

Post-adjusted provider payments could align goals of disparity reduction and quality improvement

 

 

(357) Fung V et al. Meaningful variation in performance: a systematic review. Med Care. 2010 Feb;48(2): 140-8. DOI: 10.1097/mlr.0b013e3181bd4dc3

PMID: 20057334

Summary:

  • Systematic literature review regarding statistical modeling of quality measurement or measuring variation or reliability of quality measures at 1 or more aggregated levels (physician, facility, geographic)
  • Variation most commonly evaluated at facility-level
  • Found low reliability at physician and facility level which indicates lack of appropriateness for public reporting or incentives based on such measures

Significance to Literature:

Deciding to implement a measurement program should depend upon (1) clinically meaningful variation among physicians or hospitals and (2) the logistics of effecting change at each level. The proportional variability alone should not drive discussions of when and how to intervene to improve quality.

 

 

(361) Gupta R, Arora VM. Merging the Health System and Education Silos to Better Educate Future Physicians. JAMA. 2015 Dec 8; 314(22):2349-50. doi: 10.1001/jama.2015.13574

PMID: 26647251

Summary:

  • Academic Medical Centers (AMCs) have a unique responsibility to provide the next generation of physicians with the skills to effectively practice value-based care.
  • In order for AMCs to accomplish their dual missions of high quality care and promoting new models of value-based care and population health, the authors offer three steps to follow:
  • Support physician leaders to bridge the gap between graduate medical education and the health system
  • Promote programs that directly link physician leaders with residents in order to promote innovation and culture change
  • Engage residents in projects that will serve the missions of both the education and health sectors of AMCs

Significance to Literature:

As the US health system is shifting from volume to value, AMCs should align efforts between health system and graduate education leaders to produce physicians well-versed in value-based care.

 

 

(362) Krauth C et al. Would German physicians opt for pay-for-performance programs? A willingness-to-accept experiment in a large general practitioners sample. Health Policy. 2016 Feb; 120(2):148-58. doi: 10.1016/j.healthpol.2016.01.009. Epub 2016 Jan 21.

PMID: 26852868

Summary:

  • Mail survey with questionnaire and willingness-to-accept experiment was conducted among German general practitioners (GPs) to determine if, and at what required bonus, GP’s would participate in a P4P program
  • Results showed divided views of P4P with theoretical participation rates ranging from 28% to 50% when performance bonuses were increased from 2.5% to 20%
  • Main reasons for reservation on participation included feasibility of program and fear of unintended consequences

Significance to Literature:

Better evidence for P4P effectiveness and proper tailoring of P4P programs through communication with providers are both necessary to increase P4P participation willingness

 

 

(377) McKethan A, Jha AK. Designing Smarter Pay-for-Performance Programs. JAMA. 2014 Dec 24-31;312(24):2617-8. doi: 10.1001/jama.2014.15398.

PMID: 25375310

Summary:

  • Author proposes more targeted P4P programs that emphasize improving care for smaller subgroups of patients at higher risk of poor outcomes
  • A necessary component of such a program would be an effective prediction model capable of identifying patients that would benefit most from greater attention and support
  • Payers could substantially increase bonuses available for patients with higher risk of poor outcomes; reducing the likelihood of rewarding providers whose patients would likely do well regardless of incentives

Significance to Literature:

Instead of simply changing bonus sizes or performance measures, targeting at-risk patients for P4P incentives may have a greater effect on health outcomes.

 

 

Key Article

(383) Allen T, Mason T, Whittaker W. Impacts of pay for performance on the quality of primary care. Risk Manag Healthc Policy. 2014 Jul 2;7:113-20. doi: 10.2147/RMHP.S46423. eCollection 2014.

PMID: 25061341

Summary:

  • General overview of P4P theory and applications and their impact on the quality of primary care in the UK
  • Adoption of P4P is increasing worldwide despite ambiguous evidence for its efficacy and continued difficulty with the evaluation of programs
  • The authors outline a list of potential unintended consequences including: measure fixation, short-termism, manipulation of measures, gaming, etc.
  • Discussion of the United Kingdom’s ten-year-old Quality and Outcomes Framework (QOF) program, the largest P4P example in primary care
  • Performance initially improved in a stepwise fashion for incentivized areas of quality, but quickly regressed to pre-QOF rates of improvement after the first year of implementation. (i.e. Outcomes were slowly improving prior to QOF. Outcomes improved quickly during the initial QOF year. Thereafter, outcomes continued to improve, but as slowly as they had in the pre-QOF era)

Significance to Literature:

P4P evidence is mixed and difficult to analyze. New schemes must be designed from the beginning to better allow evaluation, including control and treatment groups coupled with before and after data. Evidence for rapid improvements in performance were observed for only the first year of QOF.

 

 

Key Article

(408) Asch et al. Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial. JAMA. 2015 Nov 10;314(18):1926-35. doi: 10.1001/jama.2015.14850.

PMID: 26547464

Summary:

  • Multicenter cluster randomized clinical trial comparing the effect of physician financial incentives, patient financial incentives, shared physician and patient incentives, and no incentives on reducing levels of low-density lipoprotein cholesterol (LDL-C) in high cardiovascular risk patients
  • Patients were deemed eligible based on Framingham-Risk Scores, LDL-C levels, and presence of coronary artery disease
  • Primary care physicians and patients were randomly assigned to each group. Physicians were each eligible to receive up to $1024 annually per patient and patients could receive up to the same amount via entrance into daily lotteries based on medication adherence
  • Only patients in the shared physician/patient incentive group achieved significantly reduced LDL-C levels compared to the control group after 12-month intervention
  • Shared incentive average was 126.4 mg/dl compared to 136.4 mg/dl in the control group

Significance to Literature:

Promising evidence for physician and patient shared incentives in P4P primary schemes and an indication for further research

 

 

(409) Waddimba et al. The Moderating Effect of Job Satisfaction on Physicians’ Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines. Med Care Res Rev. 2016 Feb 9. pii: 1077558716628354. [Epub ahead of print]

PMID: 26860890

Summary:

  • Retrospective cohort study examining the indirect, moderating effect of professional satisfaction on adherence to P4P diabetes guidelines within New York’s Value of Care Plan (VOCP)
  • From 2002-2003 “Quality Targets and Incentives” survey was responded to by 290 eligible PCP’s
  • Survey collected data on the attitudes of PCP’s regarding both P4P in general and VOCP
  • Results showed that physicians who were dissatisfied with their practice were only motivated to adhere to diabetes guidelines which favored their personal inclinations and were also less likely to adhere when social pressures urged them to comply to guidelines
  • Strong awareness of measures and belief in their efficacy, as well as satisfaction with the value of financial incentives, increased adherence among discontented physicians
  • “Neither attitudinal nor social pressures significantly influenced satisfied physicians” (They adhered more to the guidelines.)

Significance to Literature:

More satisfied providers adhere more to P4P incentivized diabetes guidelines

 

 

(411) Kondo et al. Implementation of Processes and Pay for Performance in Healthcare: A Systematic Review. J Gen Intern Med. 2016 Apr;31 Suppl 1:61-9. doi: 10.1007/s11606-015-3567-0.

PMID: 26951276

Summary:

  • Systematic review of 41 P4P trials and observational studies, as wells as key informant (KI) (P4P experts) interviews, was issued by the Veterans Health Administration to “better understand the implementation factors that modify the effectiveness of P4P”
  • Published literature and themes from the KI interviews were consistent in indicating that:
  • Measures should be transparently evidence-based, and measures that are viewed as clinically important to providers are superior to those that target efficiency or productivity
  • Incentives must be large enough to motivate behavior (hypotheses range from 5-15%) while not undermining the cost-effectiveness goals of P4P programs
  • P4P programs must be flexible and able to utilize ongoing measurement of data and provider input to evaluate initiatives on a regular basis
  • Flexibility should to be used to shift focus and adjust incentivized measures to target areas of poor performance

Significance to Literature:

Evaluation of implementation factors that will set P4P programs up for success

 

 

(412) Francis J, Clancy C. Implementing Performance Pay in Health Care: Do We Know Enough to Do It Well?. J Gen Intern Med. 2016 Apr;31 Suppl 1:6-7. doi: 10.1007/s11606-015-3574-1.

PMID: 26951268

Summary:

  • Follow-up article to Kondo and colleagues (411)
  • P4P incentives are difficult to structure because of measurement challenges and inability to define clinical quality for individual patient encounters
  • Value depends on perspective: population versus individual patient
  • Authors urge that it is not enough to simply understand if incentives make a difference in clinical quality. It is much more important to know how they make a difference
  • Qualitative aspects often not reported in the literature, but are arguably what makes a P4P or value-based initiative successful
  • Point out the findings of Kondo et al. are quite consistent with the literature on “general management” and “audit and feedback in healthcare.”

Significance to Literature:

Parallels between P4P implementation and the business management world are striking, and therefore a wealth of empirical evidence (qualitative and quantitative) already exists to inform the effective initiation of P4P programs

 

(413) Tsiachristas et al. Impact of financial agreements in European chronic care on health care expenditure growth. Health Policy. 2016 Apr;120(4):420-30. doi: 10.1016/j.healthpol.2016.02.012. Epub 2016 Mar 2.

PMID: 26971018

Summary:

  • Integrated chronic care and healthcare expenditure growth was compared between 9 European intervention countries who had implemented financial agreements with an emphasis on healthcare delivery coordination and 16 control countries with traditional financial structures such as fee-for-service
  • Examined financial agreements included  pay-for-coordination (PFC), P4P, or all-inclusive payments (bundled or global payments)
  • OECD and WHO data from 1996-2013 showed:
    • PFC and all-inclusive payment countries had reduced outpatient expenditure growth immediately after implementation
      • 216.60 US$ per capita for those with all-inclusive payments
    • P4P countries had decreased hospital and administrative cost growth immediately after implementation
    • In the total 4-year period after implementation of financial agreements, P4P administrative expenditure growth. All-inclusive payments continued to show reduced outpatient expenditure growth.

Significance to Literature:

Large scale healthcare financial agreements composed of aspects for PFC, P4P, and all-inclusive payments could be used to reduce rising healthcare costs.

 

(417) Ogundeji et al. Pay for performance in Nigeria: the influence of context and implementation on results. Health Policy Plan. 2016 Apr 1. pii: czw016. [Epub ahead of print].

PMID: 27036415

Summary:

  • Significant variation has been seen between P4P implementation sites in Nigeria
  • Semi-structured interviews were conducted with 36 health workers to explore contextual factors that influenced the implementation of P4P schemes
  • Four main themes summarized the interviewees’ comments on the effectiveness of P4P implementation:
    • Uncertainty in obtaining the incentive because of delays in payment and ineffective communication
    • Health workers’ (not including physicians) knowledge of the P4P scheme
    • Role of the health facility manager in implementation
    • Factors which affected motivation and performance under the P4P scheme
  • Authors offer recommendations to improve P4P implementation and management

Significance to Literature:

Certain implementation factors, including target payments to administrators and nurses, “can affect the impact of P4P schemes on top of the main design features”

 

(426) Bunkers et al. Value-based physician compensation: a link to performance improvement. Healthc Financ Manage. 2016 Mar;70(3):52-8.

PMID: 27183759

Summary:

  • Mayo Clinic Health System (MCHS) implemented a value-based physician compensation model in 2014 across parts of Minnesota and Wisconsin, including Mayo Clinic in Rochester, MN
  • MCHS’ value-based scheme tied five percent of a physician’s total compensation to the metrics focused on outcomes, safety, and patient experience during the first year:
    • 1% for outcomes measures by specialty
    • 2% for safety with e-prescriptions and medication reconciliation
    • 2% for patient experience scores
  • All performance measures improved in all regions of MCHS
  • Key elements of the implementation and management process were identified:
    • Methodical rollout of program with full leadership support
    • Robust physician performance management tools
    • Multi-faceted communication strategy
    • Data transparency and frequent reporting
    • Substantial physician support

Significance to Literature:

The first-year success of MCHS’ value-based physician compensation plan indicates significant gains in performance can be achieved even with relatively low financial risk (max 5% at stake)

 

Key Article

(434) Henkel RJ, Maryland PA. The Risks and Rewards of Value-Based Reimbursement. Front Health Serv Manage. 2015 Winter;32(2):3-16.

PMID: 26817266

Summary:

  • Lessons from leaders of the largest not-for-profit healthcare system in the United States, Ascension Health, on how to engage patients and providers in creating new ways to better coordinate care in the shift to value-based payment models
  • Ascension itself is committed to keeping the Quadruple Aim as the goal for this transition
  • Review of value-based models to choose from, including P4P, shared savings, bundled payments, shared risk, global capitation, and provider-sponsored health plans
  • Analysis of options for healthcare systems and providers should include:
    • Evaluation of market readiness
    • Preparedness to invest in resources to improve transition and care management
    • Recognition that cost-structure adjustments will need to be made as inpatient volumes decline
  • Some healthcare systems are considering becoming their own payers to accommodate this change

Significance to Literature:

Recommendations from executives of Ascension Health on how to best facilitate the volume-to-value transformation

 

(450) Averill RF et al. Rethinking Medicare Payment Adjustments for Quality. J Ambul Care Manage. 2016 Apr-Jun;39(2):98-107. doi: 10.1097/JAC.0000000000000137

PMID: 26945288

Summary:

  • Payment reforms have largely been focused on following process measures which has resulted in a highly complex attempt to measure value
    • IOM has observed that “thousands of measures are in use today to assess health and health care” but “their sheer number, as well as their lack of focus, consistency, and organization, limits their overall effectiveness in improving performance of the health system”
  • Authors indicate lessons from the Inpatient Prospective Payment System (IPPS) and its use of Diagnosis Related Groups (DRGs) should be used to guide quality measurement. These lessons include: focus on outcomes, set national standards, be clinically meaningful, create the right incentives
  • The Incentivizing Health Care Quality Outcomes Act of 2014 looks to replace Medicare’s disjointed quality measurement system focused on process measures with a coordinated outcome-based system for all health care delivery organizations
    • The Outcomes Act focuses on five potentially preventable events (PPEs) which represent the majority of preventable expenditures including: complications, admissions, readmissions, emergency department visits, and outpatient procedures and diagnostic tests
  • Many state Medicaid outcome-based payment reforms are consistent with the Outcomes Act have yielded real results
    • Eg) In the first three years of a potentially preventable readmission project by the Minnesota Hospital Association, readmissions have been reduced by 19%
  • Simulation was performed to estimate savings for reducing PPEs by different amounts
    • Eg) Lowering PPEs by 30% over five years resulted in an estimated 0.88% reduction in Medicare payments ($5.1 billion) and a 1.38% reduction in hospital operating cost ($7.9 billion)

Significance to Literature:

The Health Care Quality Outcomes Act of 2014, and similar state programs, hope to improve quality by focusing on outcomes (measured through bundled payments and potentially preventable events) instead of process measures

 

(431) Heisey-Grove D, Patel V. National findings regarding health IT use and participation in health care delivery reform programs among office-based physicians. J Am Med Inform Assoc. 2016 May 16. pii: ocw065. doi: 10.1093/jamia/ocw065. [Epub ahead of print]

PMID: 27185812

Summary:

  • The National Ambulatory Medical Care Survey (NAMCS) in 2012 and 2013 was utilized to characterize physicians’ participation in care delivery and payment reform activities and their use of health information technology (IT)
  • The survey found that 45% of physicians were participating in delivery or payment reform programs, including P4P schemes, ACO, and PCMHs
  • Those participating in delivery or payment reform programs were more likely to use certified health IT to engage patients, conduct QI activities, manage high-risk populations, and coordinate care
  • Significant variation in EHR use were noted between programs
    • Example: ACO participants were most likely to send and receive health information electronically
  • Participation in reform programs increased from 2012 to 2013 but significant attrition from and switching between program types was observed

Significance to Literature:

Assessing how physicians use IT functionalities for payment and delivery reform will allow for better understanding of what is necessary for a successful transition to value-based care.

 

(432) Hussain et al. Successful Resident Engagement in Quality Improvement: The Detroit Medical Center Story  J Grad Med Educ. 2016 May;8(2):214-8. doi: 10.4300/JGME-D-15-00316.1.

PMID: 27168890

Summary:

  • Residents at Detroit Medical Center helped developed an interactive electronic health record (EHR) checklist to monitor real time gaps in 40 process measures while also implementing a P4P model
  • The project focused on 14 of the newest quality metrics which were process measures related to stroke (8 metrics) and venous thromboembolism (VTE) prophylaxis (6 metrics)
  • Over the course of 12 months, the VTE prophylaxis score improved from 88.5% to 100%
    • Stroke care process measures reflected a similar trend
  • The remaining 26 process measures remained above 95% compliance

Significance to Literature:

A combination of P4P incentives, an interactive EHR checklist, and resident quality improvement leadership may improve compliance with VTE prophylaxis and stroke care process measures

 

(433) Augustine S. Does Money Really Talk? A Resident-Driven Pay-for-Performance Pilot. J Grad Med Educ. 2016 May;8(2):277-8. doi: 10.4300/JGME-D-16-00105.1.

PMID: 27168906

Summary:

  • Commentary on the resident-driven P4P (432) by Hussain et al. in the same journal issue
  • Residents achieved improvement in process metrics for prevention of venous thromboembolism (VTE) and stroke care
  • Compliance rates for VTE and stroke performance measures increased from a baseline of 88.5% and 88%, respectively, to 100% at 12 months for both categories
  • Author raises questions and concerns regarding the study, including:
    • With high baseline compliance rates, did these improvements result in cost savings and improved outcomes?
      • $250,000 startup cost was required for EHR technology support
    • Did some patients receive unnecessary treatment for VTE and stroke care to reach the 100% compliance rate?
    • Were patients excluded from the denominator by being inappropriately deemed ineligible for the study?

Significance to Literature:

“Hussain et al. should be applauded” for integrating P4P and QI into their training programs, but it is unclear whether “clinically relevant patient outcomes could be achieved through a resident-run P4P program using decision support tools”

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