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Pay for Performance

Health Policy
by

Elisa Boody

on 6 August 2015

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Transcript of Pay for Performance

Pay for Performance
OBSTACLES TO IMPLEMENTATION
OPERATIONAL: Are operations capable of supporting reimbursement

ANALYTICAL: Traditional claims payment analyses need to be expanded to include estimates of outcomes and efficiency

DEVELOPMENTAL: Payer-provider relationships must be developed
What is Pay for Performance?
Goals of P4P
Who are the key players in P4P?
How to Develop a P4P Program
WHAT MODELS EXIST
California (2001)
In response to managed care, plans and providers created a set of quality performance measures and public "report cards"
CMS (2005)
10 large, multi-specialty physician practices phased in quality standards for preventive care and the management of common chronic illnesses
United Kingdom (2004)
Quality and Outcomes Framework created 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience
Pilot Programs
P4P Timeline
BENCHMARKS
Should CMS lead the P4P movement?
Billing code model
Inconsistent study results
Medicare population is not representative of the general population
Not well suited for data mining
Can authorize pilot studies
CONCLUSION
~ We know Fee-for-service has led to rising costs.
~ We also know Fee-for-service does NOT usually take quality of care into account

~ BUT can P4P meet its own goals?

~ Need to heavily test the programs to measure this
~Where?
~How?
Providers aim to achieve specific performance measures
Payment is based on achievement of those predetermined measures
Sometimes referred to as value based purchasing, P4P is a direct contrast to the current fee for service payment model
PROVIDERS
EMPLOYERS
LIFE SCIENCES
PAYERS
PATIENTS
Improve patient outcomes
Promote health care integration
Promote patient-provider communication
Curb health care costs
Physicians
NPs
PAs
Nurses
Hospitals
Practice Groups
Solo Practitioners
Drugs
Devices
Diagnostics
Tools
Private
Public
Mid 1990s
Late 1990s
Mid 2000s
Early 2000s
Early 1990s
501(c)(3) that aims to improve health quality
Utilizes evidence-based standards, measures, programs, and accreditation
Administer the Healthcare Effectiveness Data and Information Set (HEDIS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey
Significant HMO expansion

Payment capitation introduced

HIPAA enacted, creating coding and transaction standards
PPO risk-sharing models become more popular, replacing capitation

P4P becomes more popular
HEDIS measures used as indicators
Peer review and comparison

IOM publishes
To Err is Human
Medical errors cause 98,000 preventable deaths
IHA California P4P initiative, Bridges to Excellence, and CMS three year Premier Hospital Quality Initiative launched

NEJM reports:
Patients receive only 55 percent of recommended care
Between 30 and 40 percent of Medicare expenditures are “wasted on inappropriate or unnecessary care"

By 2004, more than 80 P4P programs

In 2005, CMS begins three year Physician Practice Group pilot

HEDIS is used by about 90 percent of managed care plans

Congress proposes, but doesn't enact, a Value-Based Purchasing Model
The National Committee for Quality Assurance is formed in 1990
Fewer than 10 P4P programs in place
Existing Contractual Obligations
Stark referrals and kickback arrangements
Gainsharing
Integrity of Medical
Data
Malpractice or a reduction in medically necessary services
Legal Concerns
Elisa Boody and Krystyna Dereszowska
FRAMING THE RIGHT QUESTIONS
What aspect(s) of health care delivery do we want to improve?
What behaviors do we want to change?
Which physicians will want to participate or be affected?
What are the pros and cons of targeting individual physicians or groups?
What do we desire as an outcome of our P4P initiative?
Baby steps!
Non- Financial Incentives
BONUS PAYMENTS
Bonus or tiered bonus for achievement of a predetermined threshold
Tiered bonus based on comparative ranking
Bonus for demonstration of improvement
PAY FOR PARTICIPATION
Paid for time spent at state-sponsored collaborative quality improvement workgroup meetings
PAY FOR PROCESS
Automatic payment of $10 every time one of the PCP’s age-appropriate female adult patients receives a biannual mammogram.
PERFORMANCE BASED FEE SCHEDULE
The PCP is paid 105 percent of the usual fee schedule if strong performance on several performance metrics distinguishes the PCP from other PCPs
QUALITY GRANTS
May apply for a grant to implement a patient registry system to facilitate tracking of patients in need of preventative screenings
COMPARING INCENTIVE MODELS
Performance Profiling
Public Recognition
Technical Assistance
Auto-Assignments
Reduced Administrative Requirements
Establishing and Tracking Benchmarks
:

- Performance often not visible until decades later (Think: preventing chronic disease)
- Patients change insurance/jobs
- Patients no longer stay a lifetime with one provider, more mobility
- Co-morbidities by the time symptoms appear
- Lack of coordination of care: Multiple specialists who are not in the same system

Providers
Life Sciences
Employers
Payers
Paying for Quality
ROAD MAP
- What is Pay for Performance? (P4P)
- Who are the Players?
- What are the goals?
- Pointers for Development
- Review of some models
- What do we know from pilot programs?
- What are some barriers?
- Review of legal concepts involved
- What's the best setting to try P4P?
Full transcript