gary j. young 1 designing and implementing pay-for-performance programs: ongoing challenges gary j....

Gary J. YoungGary J. Young 11

Designing and ImplementingDesigning and ImplementingPay-for-Performance Programs:Pay-for-Performance Programs:

Ongoing Challenges Ongoing Challenges

Gary J. Young, J.D., Ph.D.Gary J. Young, J.D., Ph.D.Boston UniversityBoston University

Presentation for AHRQ Annual MeetingPresentation for AHRQ Annual MeetingSession on How Pay-for-Performance Fits with a Value Session on How Pay-for-Performance Fits with a Value

Agenda Agenda

September 28, 2007September 28, 2007

Financial support from Agency for Healthcare Research and Financial support from Agency for Healthcare Research and Quality; Robert Wood Johnson FoundationQuality; Robert Wood Johnson Foundation


P4P: Will it Work?P4P: Will it Work?Recent evidence points to modest gains from P4P in terms of provider adherence.Recent evidence points to modest gains from P4P in terms of provider adherence.

Selected Findings:Selected Findings:

Rosenthal et al. (2006) Relative increase of 3.6 percentage points for cervical Rosenthal et al. (2006) Relative increase of 3.6 percentage points for cervical cancer screeningcancer screening

Levin-Scherz et al. (2006)Levin-Scherz et al. (2006) Relative increase of 2-19 percentage points for diabetes measuresRelative increase of 2-19 percentage points for diabetes measures

Lindenauer et a. (2007) CMS Premier demonstration: Relative increase of 2.6 Lindenauer et a. (2007) CMS Premier demonstration: Relative increase of 2.6 percentage points for AMI measures; 3.4 points for pneumonia measures; 4.1 percentage points for AMI measures; 3.4 points for pneumonia measures; 4.1 points for heart failure measures. points for heart failure measures.

Young et al. (2007)Young et al. (2007)Absolute increase of 7 percentage points for diabetes measure (e.g., eye exam)Absolute increase of 7 percentage points for diabetes measure (e.g., eye exam)


Key Challenges Key Challenges

Provider Engagement Provider Engagement Unit of AccountabilityUnit of Accountability Quality MeasuresQuality Measures Provider CapabilityProvider Capability Incentive StructureIncentive Structure Data Systems and MeasurementData Systems and Measurement Unintended ConsequencesUnintended Consequences


Supporting Research7 Demonstration Sites – Rewarding Results

•Surveys of Physicians (over 4000 surveyed; approximately 1500 responses)

•Interviews with over 60 Senior Managers of Physician Organizations

•Focus Groups with Providers and Payers

•Site Visits to Provider Organizations

•Findings of Other Researchers


Provider Provider EngagementEngagement

Physicians appear Physicians appear comfortable with the concept comfortable with the concept of P4P.of P4P.

----Strong preference for Strong preference for incentives linked to incentives linked to qualityquality vs. vs. utilization or productivityutilization or productivity


Physicians should be rewarded financially when they provide higher quality care.

4.9%

5.1%

5.7%

10.4%

13.5%

6.7%

54.2%

40.5%

43.3%

26.0%

35.6%

42.1%

5.3%

4.5%

2.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Rochester

Mass

California

Percent of Respondents

Strongly Disagree Disagree Neutral Agree Strongly Agree

Survey Results


Financial incentives are an effective way to improve the quality of health care.

7.0%

8.4%

19.5%

21.2%

18.8%

45.6%

39.8%

44.6%

11.2%

13.6%

23.0%4.8% 8.8%

16.7%

17.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Rochester

Mass

California

Percent of Respondents

Strongly Disagree Disagree Neutral Agree Strongly Agree

Survey Results


Provider EngagementProvider Engagement Physicians do not appear to have a strong Physicians do not appear to have a strong

understanding of the P4P programs in which understanding of the P4P programs in which they participate.they participate. Conventional forms of Conventional forms of communicating w/ providers appear communicating w/ providers appear inadequate (very Low physician survey inadequate (very Low physician survey scores regarding understanding of scores regarding understanding of programs). programs).

Many physicians appear to feel Many physicians appear to feel disenfranchiseddisenfranchised. Physician involvement in . Physician involvement in program design can help secure buy-in (e.g., program design can help secure buy-in (e.g., selection/modification of measures).selection/modification of measures).


Unit of AccountabilityUnit of Accountability

Sponsors face difficult choices and Sponsors face difficult choices and possible tradeoffs between selecting possible tradeoffs between selecting individuals versus organizations. individuals versus organizations.

-- systems engineering vs. -- systems engineering vs. physician physician initiative initiative

-- stimulating investment in QI-- stimulating investment in QIinfrastructure vs. enhancing infrastructure vs. enhancing engagement of front-line providers.engagement of front-line providers.


Quality MeasuresQuality Measures

Physicians generally comfortable Physicians generally comfortable with standardized measures such as with standardized measures such as HEDIS and HQA.HEDIS and HQA.

--Outcomes vs. Process --Outcomes vs. Process MeasuresMeasures

--Specialists and Non-Acute Care --Specialists and Non-Acute Care SettingsSettings


Provider Capability Provider Capability

Providers reveal anxiety about capabilities Providers reveal anxiety about capabilities to perform well on quality measures.to perform well on quality measures.

--Hospitals with well developed QI --Hospitals with well developed QI infrastructure appeared to have a distinct infrastructure appeared to have a distinct

advantage in BCBSM P4Padvantage in BCBSM P4P

With limited provider capability, one-time With limited provider capability, one-time performance gains may be common. performance gains may be common.

--In some situations, learning goals --In some situations, learning goals should possibly precede performance should possibly precede performance goalsgoals


Overview: Six-Year Trends in RIPA Diabetes Care(n=334)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1999 2000 2001 2002 2003 2004

Mea

n A

dh

eren

ce R

ate

(pat

ien

ts p

er p

hys

icia

n)

HbA1c Check Urinalysis LDL Check Retinal Exam

Pre-Incentive Post-Incentive


Incentive StructureIncentive Structure Both program sponsors and Both program sponsors and

providers are divided on many providers are divided on many issues regarding incentive issues regarding incentive structure.structure.

--Attainment vs. --Attainment vs. Improvement Improvement

--Bonus only vs. Penalties --Bonus only vs. Penalties (e.g., (e.g., withholds)withholds)


Data Systems and Data Systems and Measurement Measurement

Providers have strong concerns Providers have strong concerns about data reliability and validity. about data reliability and validity.

--Claims vs. Charts (appeals --Claims vs. Charts (appeals process/reserve fund)process/reserve fund)

-- Small Numbers (composite scores -- Small Numbers (composite scores

multi-payer initiatives)multi-payer initiatives)


Unintended Unintended ConsequencesConsequences

Physician surveys reveal Physician surveys reveal no majorno major concerns about UC.concerns about UC.

----Some studies outside healthcare Some studies outside healthcare point to negative impact on innovation.point to negative impact on innovation.

-- P4P in safety net settings may -- P4P in safety net settings may pose pose unique risks.unique risks.


Concluding CommentsConcluding Comments P4P can lead to gains in clinical quality, but the P4P can lead to gains in clinical quality, but the

magnitude of the gains may be quite modest and magnitude of the gains may be quite modest and time-limited, particularly without substantial time-limited, particularly without substantial improvements in provider infrastructure for improvements in provider infrastructure for quality measurement and improvement. quality measurement and improvement.

Physicians do appear comfortable with P4P as a Physicians do appear comfortable with P4P as a concept, but have certain concerns with the way concept, but have certain concerns with the way P4P programs have been designed and P4P programs have been designed and implemented.implemented.

Program sponsors face many daunting challenges Program sponsors face many daunting challenges in designing and implementing programs. in designing and implementing programs.

gary j. young 1 designing and implementing pay-for-performance programs: ongoing challenges gary j....

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