Related Articles:

Poll Finds Physicians Very Wary of Pay for Performance

Physician Buy-In is Essential for Pay for performance

The Dark Side of P4P

Pay for performance—For Whom the Bell Tolls

101. The problem with pay for performance is that it is based, ultimately on a zero sum foundation. Healthcare currently has set fee schedules at its foundation, and does not obey market forces. The "premium" paid for performance does not consider that in free markets consumers are indeed willing to pay a premium when they accept the value added. As an example, Chanel can charge far more than the cost of its product's manufacture and distribution due to its ongoing reputation and maintenance of quality. However, in this example, the consumer is the actual indivdual who buys and receives the product. The present way in which the vast majority of healthcare is purchased has the patient consumer as a 3rd party from the actual financial transaction. The parties involved at the care level do not have any real say in the negotiation of this transaction, or the establishment of a "fair value". I agree that medicine has a way to go to ensure certain basic standards of care and quality. I am not sure that this is the way to achieve that goal.

102. The biggest challenge to implementing these programs will be whether the payors are honest about the creation of new dollars for the reward component. If they simply redistribute existing dollars, i.e., fail to share the savings, they will fial miserably.

103. There still is insufficient funding of these programs. It is not much of an incentive to work all year and earn $200-$500 of withhold return. The carriers really need to put large NEW dollars in the program to get any true incentivization.

104. The focus on improving the value of health care will remain with us for some time. Identifying ways to promote more consistent higher quality outcomes for less cost are challenging and I believe current pay-for-performance structures are not quite there as yet. Defining quality with enough accuracy and with enough evidence-based outcomes to apply to a large portion of physicians remains difficult. Applying pay-for-performance solely to hospitals is a flawed approach. However, the early experience in pay-for-performance with hospitals suggests that there is improvement in outcomes for many. Over time there will be compression at the top end of the curve and troubles distinguishing performance in a manner which can allow differential payment.

105. Solely dependent on the choice of measures. If you use metric A, everyone might be doing well; use metric B and no one might be doing well. Regardless of the metric you have the same performance...

106. It is important that we improve quality of care. This is not a good way to do it. It is demeaning to well intentioned physicians. Also it will be nearly impossible to be fair.

107. should be gearde toward " pay for improvement" and the measured should be driven by physiciams and not payors.

108. P4P programs cannot be structured with a "negative" incentive for not meeting goals.

109. It is difficult to determine WHICH incentives to reward and how to WEIGH each incentive. You could develop behaviors which are undesirable.

110. The devil is in the details. How is the plan structured? What performance measures are being measured? Is the "default" performance measure financialy based? All of these issues need to be resolved for any plan to be accepted as a "valid" attempt to reward quality, not just another excuse to ratchet down physician's incomes...

111. The IT infrastructure needed to properly collect and reportreport data is making it difficult for physicians who are not part of big IPAs or physician groups to demonstrate outcomes. Therefore the results make it look like the big Medical groups are doing better. These big groups are getting the money. The small IPA, solo physicians and/or small groups need this money to modernize their systems.

112. 1- We need to standardize it and to have evidence based indicators for such approach. 2- Autonomy and feasibility are essential

113. set a quota get a quota Deming Punished by Rewards Alphie Cohen these references describe the dangers of pay for performance as opposed to decveloping methods to improve performance of the system as a whole

114. Pay for performance works if it is directed at issues the physician controls or has alot of influence over and IF there is an environment put in place which supports the physician and if the physicians are involved in setting it up. Non of those are in place in my organization.

115. PFP will be reinforced by payers in the future.

116. We are not participating in a P4P program that is physician specific using hospital data. The program is for the hospital only.

117. Measurement often leads to amazingly better management. P4P is a great start.

118. It would appear that these programs will be around for a while, but in the long term they will not really affect care in any meaningful way.An example in our office is the loss of pay for not seeing enough routine office visits on our patients. Most of us missed by about 5 or 6 patients. Our loss was about $45000. The material was at least 6 months old so we cannot possibly know who we need to see to make our performance goals.

119. Quality-based performance will be the hallmark of healthcare more and more as we go into the future. Costs have leveled out and it is THE differentiating factor in all of medicine . I can not emphasize its importance enought both intra- and inter-agency.

120. The programs in which we participate are hospital level, have no incentive for the physicians to improve, and will likely be hailed as a success - though most measures are process measures, not outcome measures.

121. The performance metrics need to be carefully considered to ensure that true performance goals are tied tightly to outcomes.

122. The criteria that are being used in P4P is flawed. It is claims data that can be easily obtained by the Insurance companies, but may not have clinical significance. The physicians need to be able to adjust the data on a case by case basis but this will never be allowed because it is too complex.This will cause physicians to do things just to be paid, not becausse it benefits the patient.

123. If you read the real idea about pay for performance it is about utilizing EBM and decreasing the variation in care. But, that is not how the HMO see it, it is about saving money.

124. It's about time !! :-)

125. I see pay for performance as a way for incenting and pushing forward a quality agenda within an organization and nationally for health care.

126. They are too focused to be effective in a very complex system. How to make them fair across the spectrum is a problem that is far from solution.

127. Only a relatively small proportion of the physician's total remunaration should be tied to pay for performance until there is more experience with such a pogram, and until the quality and the reliability of the performance measures can improve.

128. This is just the tip of the iceberg!!!

129. Pay for performance sounds desirable but implementation will probably be unfair. For example, it is clear for short term procedures such as a surgical procedure. HOw does that compare in paying for performance in caring for a child with cerebral palsy, or any other chronic health condition of which we have more and more. It would be unwise for a physician to dedicate him/herself to such patients

130. I have worked with the Bridges to Excellence Program as the head of the local medical society's quality improvement committee. That is one P4P program that focuses on process of care improvement and should be one that physicians embrace. Other types of programs may be problematic

131. Physician groups need to propose process metrics adn develop outcomes measures. The public expects physicians to be accountable for their performance.

132. SINCE THERE ARE PUNITIVE ACTIONS FOR POOR PERFORMANCE, THERE SHOULD BE A REWARD PROGRAM FOR EXCELLENT PERFORMANCE, THE SAVINGS ARE BEYOND YOUR IMMAGINATIONS

133. People will perform in a way that rewards their behavoir. Right now MDs are paid by how they code, reguardless of the quality. I think it will work, but the quality aspect of it must be insentivized.

134. THey need to not be based on claims data which is incomplete, and need to be able to assess decision making documentation for those situations in which physicians choose not to follow a guideline for good reasons and document why. I've not seen any programs that do this--and these physicians are the very ones that we ought to be rewarding for thinking carefully about what they do, as well as documenting those reasons...this is at the foundation of quality medicine.

135. The current reimbursement system rewards poor performance by not distingushing between high quality and poor quality. It also rewards providers who provide excessive care or achieve poor outcomes that require additional testing and procedures. Our profession needs to address the pereverse incentives of FFS reimbursment and P4P is only one of several mechanisms available.

136. I believe as we shift to the consumer driven health plans, that the insurers/TPA's will find that these programs are too unwieldy to keep going and will not yield significant enough reduction in costs to be continued.

137. this is a very hard to thing to measure. Individual outcomes vary depending on the patient, environment etc. Too many variables that are out of the doctors control. Once the patient leaves the office the doctor has no control yet would be responsible for the outcome of therapy, long term care etc.

138. P4P is a new era in healthcare. It definitely makes physicians pay attention to quality. Just mirroring how pay would be affected with P4P caused substantial changes in attitude toward quality. Unfortunately, using national guidelines and best practices it is easy to do P4P with PCP's: Family Medicine and Internal Medicine. Much more difficult with Pediatrics and the other subspecialists: Surgery, Ob/Gyn, etc. Isn't it amazing that in the past regardless of the quality of care you got paid. Now to do the best job you are incentivized. We have made the P4P program a zero budget item. Those who provide better quality care and utilization earn more and those who have below average values earn less. It is a very hard lesson to learn for some clinicians, especially when employed, that medicine is a business adn 3rd party payers and now consumers as more costs are shifted to them expect a lot of bang for their buck.

139. It is the "carrot" that is a great start. It will get momentum going in the right direction. Once the momentum is there, the cost will be prohibitive and "quality" will become the standard of care. Down the road I would expect that anything less than the standard of care will result in a "stick" - not a carrot.

140. Small rewards for "compliance". To me gainsharing is less prescriptive and more rewarding.

141. Can't implement these programs until IT programs are in place to get real time feedback on performance. These programs sound good but putting the cart before the horse.

142. If all physicians had robust computerized systems that coul "talk" to each other then physicians and the patients would be in charge of quality.(Not payers; not hospitals) Present pay for performance efforts distract Docs from the meaningful investment. Also, by paying so little for this payers and hospitals stay in charge a little longer. The Feds could encourage this by making the EHR companies solve combatability issues.

143. This is a real way of balncing the economic equation where one buys value for what they pay in healthcare

144. measures and criteria have to be clear and objective - no room for disputing the measures if you want buy-in; allow those being measured to have input in development phase; paying more for better care is increasing in acceptance by docs

145. Overall a move in the right direction, but as usual the devil's in the details. Physicians need to participate in the development so the metrics are rational and the process is fair.

146. In my regional area, the P4P program has been well received and taken very seriously by the Medical Groups/IPAs.

147. This concept is here to stay, whether it will truly metamorphasize into a significant fair reward of excellence in practice remains to be seen. My fear is that this concept will not remunerate superior preformance, but cut the reimbursement of all except physicians who fit the select criteria of those who determine which "quality" measure they wish to emphasize.

148. They are called pay-for-performance, but, as they are currently designed, they are more often punish-for-not-reporting.

149. They must have some "immediate" (short-term) and long-term consequences to be of any significance...

150. I believe it's sad that P4P is effective (which it is) and necessary--physicians shouldn't need an incentive for quality improvement.

151. The above answers cannot be absolute. I think that a pay-for -performance system should supplement, not supplant, any reimbursement system. Who sets the performance targets, which performance targets are used, how they are measured, and whether or not they are realistic or clearly evidenced-based are factors that may be relative and arguable.

152. Too hard to administer, evaluate, and make sure that there is really better quality

153. We are in the process of developing health resources management among our network of physicians. Quality indicators based on NCQA guidelines are being incorporated along with clinic specific criteria for quality measurement. Pay-for-performance methodologies have not been worked out at this point.

154. I expect, though, that pay for performance programs will change over time such that they will no longer be identified as separate programs. Physicians, healthcare providers etc will however be held responsible for the "quality" of care provided. Hopefully, the quality measures will be determined with the input from practitioners on the "front line".

155. Now that we have gone down this road, we won't turn back. We may modify our route or our ultimate destination, but now that CMS is involved I see no way to retreat.

156. the p4p "movement" is a sham for the emr agenda! .....several conceptual problems with p4p are: [1]basically, those who use paper are at a huge disadvantage from the outset; there is NO evi dence that emr DELIVERS better care, only that one can REPORT it.... [2] the true measures of "quality" in medical practice, ie did you get the diagnosis right, ie did you get the treatment right?, ie did you strike the proper BALANCE between making the patient aware of risks ( to diagnosis and to rx) and instilling confidence and hope? as einstein put it so well, "not everything one can measure counts, and not everything that counts can be measured"....what is passed off to the public and (they wish) on us is that PREVENTION-ATTENTION IS QUALITY...this is patently false....at best, what is pawned off as "quality" is a distant relative placed into the surrogate role.....the extreme case would be the doctor has ordered the mammogram, the lipids, the psa or whatever while synchron ously missing a huge disease right under his or her nose!....following a laundry list of prevention is NOT "quality"....furthermore, my views were conveyed to dr leider et al in the "three faces..." course (the course could more properly be entitled the TWO faces of "quality"!! [3] not only can we not necessarily agree on what "quality" is, but we couldnt measure it if we could....what the current "quality" fad is all about is frantically scrambling to DO SOMETHING; dont mind if it is conceptually bankrupt..... [4]even if we allow that COUNTING THINGS will bring a smile (that isnt the anatomic change i actually formulated the notion with, but so as not to be gender-specific....) to some bureaucrats and "bidnessmun", it terrifies clinicians to think of RAW DATA in the hands of the yo-yos in the government-insurance complex......case in point: hospital mortal- ity data!....remember that fiasco...the DATA WERE CORRECT.....but recall, the govmint tried its hoof at consumer-protection by stating (at least implying loudly) that some hospitals were safer, hence BETTER HOSPITALS, for having low death rates....as usual, they got it ass-backwards; little suburbia general looks wonderful vs.(my alma mater) johns hop kins hospital.....the fact that the latter is consistently voted the premier hospital in the WORLD aside, little suburbia general has any patient transferred out if they get the least bit sick (this does wonders for both the death rate and the length-of-stay!).... the tertiary centers and the big general hos pitals take the hits, clinically speaking... does the word "dumping" mean anything to you ?...it is a way of life for many for-profit establishments.....what was missing was the KNOWLEDGE AND SOPHISTICATION TO INTERPRET THE DATA....questions as simple as who is in the hospitals (race, age, dx,comorbidities, and complications involved)....did they think it wouldnt be a meaningful VARIABLE?....the com parison, even to be made at all, reflected a scary level of ignorance and simple-minded- ness....have they acquired new and finer res ources for such types of "studies"???....find someone who believes that one! [4] what is needed is the MONEY to really study this issue....things like whether a paper system does or doesnt (or can or cant) deliver the same quality?...does the money spent on emr IMPROVE the "quality" (which cant be defined or measured...recall the surrogate status of prevention tests) in the longrun?......do patients who get the surrog ate "quality" actually live longer and/or get admitted less in the longrun?.....the pros- tate cancer data are fascinating!...we diag nose it earlier, treat it earlier and more aggressively now without altering the time of death...called "lead time bias", it has enormous implications for evaluating just how valuable "prevention" is....the #1 revers ible cause of morbidity and mortality isnt measurable at all...no claim, no quit rates, no nothing....recall einstein.... [5] the ama and mgma have both properly set out some fair and sane STANDARDS for p4p pro jects....they have been and will be IGNORED ....no "new money" (just transfer funds from from the lowest quartile of the bell curve to the top quartile and leave the bell alone) .....and what does "voluntary" mean to a prac tice with paper and no six-figure kitty to go electronic? other than the objections i have raised above, it sounds ok......

157. The model I have seen seems to favor the larger group practices and small group practice or solo practitioner is left with too small a sample size so as to get little to no performance bonus.

158. It's too early to tell. We are collecting data and reporting on the pretense that we will see pay. Haven't seen it yet.

159. The best programs are those devised by provider networks, not payers. Our Clinical Integration program is developed by providers and is evidence based. We have information across the whole practice for a physician, not the small slice of a practice by an insurance company.

160. P4P has not addressed issues with specialists yet so far as I am aware.

161. our program is mostly productivity based, so really doesn't address quality very much.

162. Present programs we are looking at are primarily based on patient satisfaction and less on clinical outcomes or guideline adherence.

163. PFP should be based upon adherence to standards of care - not outcomes.

164. As more academic departments are getting involved with alternate funding (instead of fee-for-service), pay-for-performance will become more routine as a measure of ACCOUNTABILITY...

165. I am very concerned about he accuracy of data estraction and the evidence supporting these initiatives. Also of concern is the ability of this type of program to keep uo with advances in medical practice and scientific evidence.

166. Your proof reader, or someone/something else failed the pay for performance test--misspelling first answer to last question! Now,is that the fault of the writer, the editor, the proof reader, the printer, or some software? And, in any event, did it impact the outcome of the questions content and answer? (no) I believe the big pharmas want us to meet stricter guidelines to force rx use up, and by big insurers to reduce payments. Patient compliance (including cost and access, inadequate documentation and reporting comprise the bulk of under or over estimations on meeting various targets. Further, the standards are always in flux. etc etc

167. There are so many "ifs." If they reward quality of care and service, and not reduced utilization; if the goals are clear, the measurement system is clear, and MDs receive feedback DURING the year so they can improve; if it is not a "zero-sum game" where the top half are rewarded (since only 50% can be in the top half, no matter how good a job they do)...then they MIGHT be useful.

168. I do not like the term "pay for performance". We currently "pay for performance" and that is what is called fee for service and creates all the incentives for over utilization. I think we should call these programs "value based payment" since what we are trying to encourage is improved "value" for the health care dollars we spend.

169. It is highly dependent on the supervisor or manager that makes the determination. The performance can be perfect, but if the manager does not see it, refuses to acknowledge, or otherwise has bias against the provider, it may not be fair, regardless of the policy. There may also be nothing the provider can do about it, except move to a different employer.

170. The system we currently operate under is based on claims made data and we have found serious errors in the reporting of data and it has had serious in=mpact on our reimbursement, and unfortuately since some of the patients who the insurers claim have certain medical conditions and infact don't have these conditions. We are now fighting with the payor and our patients to get their medical record cleared of erronous medical conditions.

171. It could be useful if done right, e.g. percent of patients receiving proven treatment/prevention, e.g. influenza vaccine, chlamydia testing for teens/young adults, beta blockers after heart attacks, etc. However, if not done right, it's counter-productive.

172. If performance measures are influenced by the patient population cared for, then they are inherently unfair and will divert resources away from those who most need them. For example, if control of blood pressure is selected, yet the population does not have access to medications, then how can the health care provider be held accountable for society's failings.

173. As health expenses continue to rise, the payors of health care are going to increasingly expect that they get quality for their dollar. Health care services are increasingly becoming a commodity and to get top dollar you will have to deliver superior results

174. "Quality" may not be able to define in all areas in medicine. How do one define good pathology report?

175. Our ED physician group currently employs a very successful pay-for-performance program. Benefits include equity, transparency, and increase productivity.

176. These programs hold great promise if they are well-crafted and validated programs using meaningful performance measures. Done correctly, they should enhance and improve the health of individuals and the population and not just cut costs or improve the margins for payers. They should not yet be based on outcomes measures which are harder to design and require patient participation. Gaming of the system must be prohibited or the initiative will become a sham.

177. Pay for performance programs differ in terms of fairness and effectiveness depending upon the specifics.

178. Potentially helpful if criteria are carefully vetted for validity and payment schemes are monitored for fairness.

179. Positive Incentives can boost productivity but in academic settings this is usually done at the expense of availability to trainees for supervision, etc. Negative Incentives are demoralizing and lead to resentment even in high performers who end up getting the bonus for increased productivity.

180. Why not have the "patients" pay the "physicians" FULL FEE and then reimburse them based on THEIR performance? If they lead healthier life styles (lose weight, exercise etc.) or follow the advice of their "physician" (take their medication so they keep BP, cholesterol, blood sugar, etc under control.) they get reimbursed more money. This would provide an economic motivation for them to stay/be healthy. Eventually they will be healthier (at least theoretically) and would use less health care resources. However P4P has nothing to do with health. It's another insurance industry/government "scam" to make money and control the practice of medicine. "Physicians" must refuse to be the "middleman" between service users and service payers and demand direct payment from the users (patients). Also, they must "opt-out" of Medicare and refuse to see Medicare patients until the system pays a fair fee.

181. Physicians are not affected by the programs, hospitals are. Hospitals must influence physicians to change behavior. Medicare should alter physician reimbursement directly.

182. I wish we had one!

183. I think it is particularly worth looking at the IHA program in California and at the CMS demonstrations.

184. I suspect these will become a way to hold down/withhold physician payments

185. no menaigful parameters for surgical specialties ( my group) are available leaving porblems with goal establishment. also amout of money at stake is generally no adequate for the efort and resources used to effect and improvement.

186. The new generation of P4P we are now negotiating is much better with regard to incenting better quality, reducing errors, and improving efficiency. There is a sense of cooperation among payers and providers that has been lacking in the past. We'll see what happens in a few years.

187. Too much of it is subjective. Docs learn the simple measures one can monitor (eg ordering mammos etc). Look to NY experience with cardiac surgery. It helped a bit at first to publish outcomes but now all of the community surgeons refuse the tough cases and pass them on to the universities to avoid hurting their numbers with the state. The same will happen here I feel

188. Pay for performance is not yet reimbursing physicians The system does not follow individual performance In the future it will happen

189. If they are created in collaboration with physicians so the developers can understand the challenges of capturing information, evaluating that information against the criteria, and the problems that are created when the criteria are not consistent with evidence-based practice, it then has the possibility of being a good program.

190. Good only for underuse situations

191. the nature of the evaluation tool is often flawed what is easy to tabulate is not necessarily reflective of true quality preformance

192. These programs have nothing to do with quality, they are just another way for insurance companies to cut their costs.

193. Care which achieves proven outcomes accounts for a very small percentage of the overall cost of health care. Pay-for-performance initiatives must be focused on rewarding those clinicians who can provide evidence-based care efficiently, not just on certain defined quality outcomes.

194. Payors often use "Quality" as their buzz word but "costs" is their Holy Grail.

195. I think this could be a "Pandora's box." I could see physicians spending more time making sure they are meeting certain guidelines rather than treating patients. The same may be true for hospitals if the criteria and measurement of performance are not real and significant. We recently lost out on a BC-BS bonus for pneumonia care when just a few cases in a incredibly busy March had slight delays in initiating antibiotics. If "bonuses" go to only those hospitals with superior staffing we will have a situation where the "rich may get richer" and those institutions with economic and staffing challenges may fall further behind.

196. I think that currently efforts to keep P4P a bonus situation will give way to gradations of reimbursement based on gradations of meeting criterea.

197. If these programs actually reward quality, they should be helpful in promoting evidence-based medicine, they will probably improve. However, they may increase costs in some areas. If so, they may be short-lived.

198. Concerned about the death spiral effect of low performance producing low reimbursement and therefore insufficient funds to increase performance.

199. I am sorry that I do not know much about this. At first glance, the idea seems flawed.

200. In theory it is logical and good business. In the real world there will be disagreement on definitions (what is better performance and how do we measure it) and how much more should better performance receive. Solve these and it should work.