Pay-for-Performance Blunders

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P4P Confusion Reigns

[By Staff Writers] 

dhimc-book1The Minnesota Medical Association recently reported that its P4P initiatives create confusion and unnecessary administrative work for medical providers.

The association looked at programs by Blue Cross and Blue Shield, Bridges to Excellence, HealthPartners, Medica, PreferredOne, UCare and the CMS; complaining that the nine pay-for-performance programs used by state insurers each have subtle differences and often measure performance differently.

The study also found that the programs seldom adjust for variations in patients’ condition, and don’t take into account economic or demographic differences among patient groups. 


And so, will P4P initiatives be just another administrative nightmare, or promote real medical quality improvements.


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13 Responses

  1. FYI:

    According to Dr. James Feldbaum [] of the pay-for-performance initiatives will require an EMR in place to participate.

    He says that the Bush administration has recruited about 1,200 doctors nationally to adopt an EMR in their medical practice in return for higher Medicare payments. Medicare will pay the physicians extra for completing tasks online, such as when ordering prescriptions or recording the results of lab tests. The highest payments will go to those physicians who most aggressively use the technology and who score the highest in an annual evaluation.

    He opines that we will see the third party payers follow suit.
    What do you think?



  2. Preliminary CMS P4P Results

    According to a new report in Modern Healthcare, hospital costs and mortality rates are going down under the new CMS’s pay-for-performance initiatives.

    Under the Hospital Quality Incentive Demonstration [HQID] project, which began in 2003, the median hospital cost per patient has declined by more than $1,000 across the first three years of the project. And, the median mortality rate went down by 1.87 percent.

    The Premier healthcare alliance, which manages the project, reached this conclusion after analyzing more than one million patient records from more than 250 participating hospitals.

    According to another analysis, hospitals nationally could save 70,000 lives per year and cut costs by more than $4.5 billion annually if they made the same improvements as the participating hospitals over a three-year period.

    Any thoughts or comments?


  3. About PQRI

    Did you know that according to Modern Physician, just 16% of eligible physicians participated in the voluntary Physician Quality Reporting Initiative [PQRI] last year?

    It was a program that provides a 1.5% bonus payment to practices that report on quality measures, according to data released by the CMS.

    Talk about P4P!


  4. CMS P4P Data Report

    Did you know that according to the Centers for Medicare and Medicaid Services [CMS], preliminary reports by the Physician Quality Reporting Initiative (PQRI) revealed that only about 99,000 physicians and others – 16 percent – who could have reported on 74 quality measures actually did so in 2007?

    Follow-up reports in Modern Physician revealed that several specialties like anesthesiology, ophthalmology and emergency medicine had higher than average rates of participation in the program. The PQRI offered physicians who successfully reported on a designated set of quality measures a bonus payment for covered Medicare physician fee schedule services.

    The 2008 PQRI reporting period, which spans the entire calendar year, will offer the same bonus payment for reporting on 119 measures.

    And so, do doctors really want P4P; or is their “P” not worthy of the “P”?


  5. Gov. O’Malley, come get your bustin’

    Want to see an incredibly naïve and expensive plan that Maryland has for using their stimulus money that has not a chance of working – no way? Today, Maryland Governor Martin O’Malley is supposed to sign into state law former President Bush’s bankrupt P4P (Pay-for-performance) executive order from August of 2007.,0,6118960.story

    Here is the really, really stupid part of O’Malley’s plan: He intends to force the state’s private health insurance companies to apply both the government-mandated incentives as well as the fines according to doctors’ “meaningful use” of eHRs. I assume quality will be determined by the private insurance claims consultants and perhaps Ingenix-like adjustable algorithms.

    What can possibly go wrong with that plan? And what does BCBS think about being given the duty to jerk around doctors and dentists as part of a mandate? They think it’s swell.

    Jeff Valentine, a spokesman for CareFirst Blue Cross Blue Shield, congratulated O’Malley and the state legislature on what he called ‘an important first step to maximize federal stimulus funding.’”

    I wonder if CareFirst BCBS hack Jeff Valentine tweets?

    D. Kellus Pruitt; DDS


  6. Hope and Ann,

    I have many concerns about the P4P program as it relates to physician compensation. Some of these concerns are addressed above.

    It is certainly true that attempts are made to adjust for patient mix and severity of illness, but I don’t think that these adjustment methods accurately reflect the true disease severity in a patient population. I have read about cardiologists being subjected to these measurements. The most talented physicians who are known to take on the most difficult cases that others would not touch have been shown to have “worse outcomes” as measured by mortality statistics. Some of these cardiologists and the hospitals where they worked simply stopped taking on these most difficult cases, and their outcomes “improved”. Is this really helping the patients involved?

    Another example from my own practice: A local insurance company measured diabetes outcomes for each doc by calculating HgbA1c frequency of testing as well as the average A1c values for each doc’s patients. Doctors correctly pointed out that patient noncompliance is one of the biggest determinants of frequency of testing as well as A1c values. Diabetes is a disease that is really determined by compliance. If a patient was completely compliant with dietary, exercise, and medication recommendations, the patient would most likely have well-controlled diabetes, or they may even no longer have diabetes! It was agreed that non-compliant patients would no longer be counted in the calculations.

    I don’t think that the public understands all of the ways that these measurements can be manipulated and “improved”. I think that the public likes to see measurements, just like they might see for a household appliance in a Consumer Reports magazine.

    From this point of view, I think that the public probably will embrace this type of grading of providers.

    Brian J. Knabe; MD


  7. P4P Payouts

    Did you know that fewer than 7% of the jobs offering bonuses rewarded physicians for meeting quality or cost goals?



  8. Medicare Pay-for-Performance Plan Criticized Over Early Launch

    Members of organized medicine are sharply critical of a plan by the Obama administration to initiate a Medicare value-based purchasing program two years before federal law requires it. Although the 2015 start date of pay-for-performance is mandated by Congress, CMS plans to use a 2013 reporting period to determine how pay will be adjusted for some physicians in 2015.

    The health system reform law requires the Centers for Medicare & Medicaid Services to use a value-based payment modifier — another term for pay-for-performance — for some physicians starting in 2015. The modifier would adjust payments to physicians based on the quality of care they provide and how much cost they incur relative to their peers during the course of a reporting period, CMS said. All physicians in the program would be subject to the modifier starting in 2017.

    Source: Charles Fiegl, AM News [9/19/11]


  9. Pay-for-Performance Not Linked to Better Patient Outcomes

    Hospitals participating in the Medicare Premier Hospital Quality Incentive Demonstration (HQID) had no improvement in 30-day mortality or other patient outcomes compared with control hospitals participating in public reporting alone, according to the results of a study using Medicare data published online March 28th 2012, in the New England Journal of Medicine [NEJM].



  10. Pay Patients for Performance?
    [PP4P NOT P4P]

    Under “Pay-Patients-for-Performance” (PP4P), patients who meet evidence-based health care goals, such as keeping their blood pressure less than 140/90 mm Hg, or glycated hemoglobin (A1c) at less than 7%, will receive financial incentives that would be in the form of health care credits, which can be used toward discounts on medications, health insurance, procedures, and co-payments.

    Opinions or comments?

    Dr. Moody


  11. Pay for Performance Programs for Docs May Backfire

    In the journal BMJ, leading experts in health policy and behavioral economics argue that pay-for-performance (P4P) schemes — which financially reward doctors and hospitals for hitting specific, numerical targets in such matters as preventing hospital readmissions or prescribing certain drugs — are likely to do more harm than good.

    Such schemes are being adopted as a key component of the ACO strategy mandated by the health care law and are now part of the Medicare program as well as Massachusetts’ cost-control legislation and virtually all major new private health insurance payment contracts.



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