Pay-for-performance is a topic that many of us have heard of, but with all of the other issues affecting your practice, such as rising malpractice costs, increasing operational costs, and decreasing managed care reimbursements, P4P seems to be a distant thought.  You cannot afford to treat it as a distant possibility for much longer as P4P is gaining momentum quickly, and most major payers (including Medicare, BC/BS, UHC, Humana and Aetna) are currently piloting P4P programs. The goal of these programs, according to the carriers, is to “improve the quality of healthcare” and to manage costs by rewarding physicians and hospitals that succeed in delivering “efficient, effective care”.  The P4P system is based on the methodology that improved clinical outcomes will decrease healthcare costs for the payor, the employer, and the patient.  P4P is heavily geared towards primary care physicians, but many of the programs include specialists and hospitals as well. 

The heart of P4P is its focus on clinical performance measurements, although information technology and efficiency measures are now included in many P4P programs.  The following is a list of 26 clinical performance measures endorsed by The Ambulatory Quality Alliance.  It also includes measures developed by the AMA and NCQA (National Committee for Quality Assurance). 

Preventative Measures:

1. Breast Cancer Screening - percentage of women who had a mammogram during the current year, or at least one year prior
2. Colorectal cancer screening - percentage of adults who had an appropriate ( i.e. age-specific, family hx) colorectal cancer screening
3. Cervical cancer screening - percentage of women who had at least one Pap test during the current year, or the two previous years
4. Tobacco Use - percentage of patients who were questioned about tobacco use one or more times during the current two-year period
5. Advising smokers to quit - percentage of patients who received advice or counseling to quit smoking
6. Influenza vaccination - percentage of patients age 50 to 64 who have received an influenza vaccination
7. Pneumonia vaccination - percentage of patients who received an appropriate (i.e. age-specific, chronic illness) pneumococcal vaccine

Coronary artery disease (CAD):

8. Drug therapy for lowering LDL cholesterol - percentage of patients, who have CAD, who were prescribed a lipid-lowering therapy.
9. Beta-blocker treatment after heart attack - percentage of patients hospitalized with acute MI who received a prescription for beta-blocker therapy within 7 days of discharge
10. Beta-blocker therapy, post-MI discharge - percentage of patients hospitalized with an acute MI who received persistent beta-blocker treatment - 6 months after discharge

Heart failure:

11. ACE inhibitor/ARB therapy - percentage of patients with heart failure who also have LVSD, who have been prescribed an ACE inhibitor or ARB therapy
12.  LVF assessment - percentage of patients with heart failure with quantitative or qualitative results of LVF assessment recorded

Diabetes:

13. A1C management - percentage of patients with diabetes with one or more A1C test(s) conducted during measurement year
14. A1C management control - percentage of patients with diabetes with the most recent A1C level greater than 9%
15. Blood pressure management - percentage of patients with diabetes who had their blood pressure documented in the past year at less than 140/90 mm Hg
16. Lipid measurement - percentage of patients with diabetes with at least one LDL cholesterol test
17. LDL cholesterol level - percentage of patients with diabetes with the most recent LDL at less than 130 mg/dL
18. Eye exam - percentage of patients who received a retinal or dilated eye exam by an eye care professional during the current year (or during the prior year if patient is at low risk for retinopathy)

Asthma:

19. Use of appropriate medications for people with Asthma - percentage of individuals who were diagnosed as having chronic asthma during the prior year, and who were appropriately prescribed asthma medications (e.g., inhaled corticosteroids) during the current year
20. Pharmacologic therapy - percentage of all individuals with mild, moderate or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment

Depression:

21. Antidepressant medication management - percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication during the entire 12-week acute treatment phase
22. Antidepressant medication management - percentage of adults who were diagnosed with a new episode of depression and treated an antidepressant drug for at least 180 days (6 months)

Prenatal care:

23. Screening for human immunodeficiency virus (HIV) - percentage of patients who were screened for HIV during the first two prenatal visits
24. Anti-D immune globulin - percentage of D(Rh) negative, unsensitized patients who received anti-D immune globulin between weeks 26 and 30 of pregnancy

Quality measures addressing overuse or misuse:

25. Appropriate treatment for children with upper respiratory infection (URI) - percentage of patients who were diagnosed with Upper Respiratory Infection, and were not dispensed an antibiotic prescription on, or within three days after the date of illness
26. Appropriate testing for children with pharyngitis - percentage of patients, who were diagnosed with pharyngitis, who received a group A streptococcus test for the episode, and were prescribed an antibiotic

For further details on each of these measures, you can go to the AQA website at:  http://www.aqaalliance.org/performancewg.htm.

In order for these programs to assess how well a practice is meeting the clinical performance, IT, and efficiency standards set forth in the plan, they must analyze valid practice data.  Most P4P programs gather performance data from claims, but in the future they may begin to rely on practices reporting data separately, which is why P4P programs encourage improvement in health information technology.  Most programs build in added incentives for use of advanced healthcare information technology or EMR systems.  Many EMR systems can be set up to report data according to the given performance measures, but this capability would have to be programmed into the system, preferably from the beginning.  It might be a good idea to call your EMR software vendor to ensure your EMR has these capabilities if and when they are needed.  If you do not already have EMR, make this one of the requirements when choosing a new system.  Even though P4P has not been completely implemented in the market, it would still benefit your practice to know you have the capability to take it on.

Financial Incentives of P4P

So you may be wondering how these programs plan to help you set aside the extra time and effort you will need to commit to these programs.   P4P programs offer a variety of financial incentives to physicians who meet specific performance standards.  The most common of these incentives include the following:

Bonus - This method seems to be the most popular.  A practice would receive a bonus check at the end of the year, based on its ability to meet the performance standards of the particular P4P program.

Quality Grants - These are grants paid to the practice for meeting certain clinical, IT, or efficiency quality measures.

Payment Withholds - A percentage of each regular reimbursement would be kept by the program carrier according to how well the practice met it’s performance standards.

Many P4P programs offer more than one type of incentive.  Increased capitation, and added income for improvements are also ways these plans make themselves more attractive to practices and physicians. 

The Down Side

While the overall premise of P4P plans is seemingly positive, there are some concerns about the possible downsides of these models.  There is the possibility that if not designed correctly, a P4P plan could place patients from different ethnic, cultural, and socio-economic groups as well as patients with specific chronic medical conditions, (along with the physicians who treat them), at a disadvantage.  Also, most of the financial incentives are based on clinical outcomes, which could encourage doctors to drop non-compliant patients or patients with severe chronic illnesses because it will be harder for them to reach performance standards with these types of patients.  This may ultimately limit these patients' access to quality care. 

Another concerning issue is that in most P4P programs, the group, or physician has to meet certain performance standards before they become eligible for bonuses or other types of financial incentives.  This places larger practices at an advantage because they may have the added resources to commit to reaching the performance standards. 

The American Medical Association has published guidelines for fair and ethical Pay for Performance programs.  These guidelines can be found at the following website:

http://www.ama-assn.org/ama1/pub/upload/mm/-1/finalpfpguidelines.pdf

I recommend starting your research on the subject now rather than later, so that when you are approached by a payor offering a P4P program, you will know what questions to ask and what to expect the impact to be on your practice. 

Some great resources for P4P information include the following:

Bridges to Excellence - http://www.bridgestoexcellence.org
American Medical Association - http://www.ama-assn.org
Medical Management Association - http://www.mgma.com
The Integrated Healthcare Association - http://www.iha.org
Medicare - http://www.cms.hhs.gov
National Committee for Quality Assurance - http://www.ncqa.org

David H. Glusman, CPA, DABFA, Cr.FA, CFS is Co-chair of our Healthcare Services Group and has over thirty-three years of experience providing specialized services to group medical practices. If you have any questions whether your practice can meet health information technology standards and performance measures, please contact David. Contact David at dglusman@marg.com.