Question

You have been asked to explain to a group of physicians how the concept of pay-for-performance may affect quality and utilization.

Answer 1

"Pay-for-performance" is an umbrella term for providing good quality, efficiency, and overall excellent health care. It is progressively developed worldwide by commercial health care and the Centers for Medicaid & Medicare Services to afford unambiguous financial encouragement to individual physicians, provider groups, hospitals, and health care systems for the provision of high-quality hygienic health care. These planning provide economic incentives to hospitals, physicians, and other health care providers to carry out such development program and achieve most favorable outcomes for the patients. The quality measures used in pay-for-performance generally described into the four categories;

A• Process measures assess the performance of activities that have been demonstrated to contribute to positive health outcomes for patients. Examples include whether or not aspirin was given to heart attack patients or whether patients were counseled to quit smoking.

B• Outcome measures refer to the effects that care had on patients, for example, whether or not a patient's diabetes is under control based on laboratory tests.

C• Patient experience measures assess patients' perception of the quality of care they have received and their satisfaction with the care experience. In the inpatient setting, examples include how patients perceived the quality of communication with their doctors and nurses and whether their rooms were clean and quiet.

D• Structure measures relate to the facilities, personnel, and equipment used in treatment. For example, many pay-for-performance programs offer incentives to providers to adopt health information technology.

Key Players in Pay-for-performance: Following is a listing of the key organizations either sponsoring or working in the physician pay-for-performance arena:

Ambulatory Care Quality Alliance (AQA): This coalition of health plans, physicians, business and government, which meets several times annually, is working to obtain consensus on how best to measure physician performance, and how to efficiently collect and aggregate data.

Centers for Medicare and Medicaid Services (CMS): CMS launched its Physician Quality Reporting Initiative in 2007.

AMA Physician Consortium for Quality Improvement: This membership entity is advocating for use of evidence-based clinical performance measures and approving identified measures, with the intent of urging P4P programs to adopt the measures.

Bridges to Excellence: This not-for-profit organization of large employers is developing programs to recognize and reward providers who meet certain standards of care.

Conceivably the preeminent known of the programs under the law that will pay for performance are accountable care organizations (ACOs)-groups of providers that agree to coordinate care and to be held accountable for the quality and costs of the services they provide. Three other programs are described below;

• Value-based purchasing: The Affordable Care Act also expands pay-for-performance efforts in hospitals by establishing a Hospital Value-Based Purchasing Program. Started from October 1, 2012, and the hospitals were rewarded for how well they perform on a set of quality measures as well as on how much they improve in performance relative to a baseline. The better a hospital does on its quality measures, the greater the reward it will receive.

• Physician quality reporting: The health care law also extends through 2014 the Medicare Physician Quality Reporting System that provides financial incentives to physicians for reporting quality data. Beginning in 2015 the incentive payments will be eliminated, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced.

• Medicare Advantage plan bonuses: The Affordable Care Act also provides for bonus payments to Medicare Advantage plans that achieve at least a four-star rating on a five-star quality rating scale, beginning in 2012. In November 2010 Centers for Medicaid & Medicare Services announced that it would replace this provision with a demonstration project in which bonus payments would be awarded to Medicare.