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201. Have potential for improving quality and lowering costs. Must be carefully structured. Must have adequate dollars involved. Muat be carefully rolled out to physicians and to the public. Must be reviewed regularly to determine anticipated and unanticipated outcomes.

202. It is fair if there is a valid way to measure performance.

203. Good idea as long as it is simple and reflects quality patient care i.e., beta blockers and aspirin after an MI, ACE inhibitor in people with reduced LV function, etc.

204. There is a plethora of these programs. Some are fair;others are not. Some programs are based on productivity regardless of quality of care (morbidity) or patient satisfaction.These programs put the pressure of financial penalities if a certain goal is not achieved. other programs raise the productivity goal every year which realy frustrates many clinicians

205. As usual, the methodology is key.

206. We need to get rid of the idea that physicians are "rewarded" for their work instead of compensated like everyone else. I can't remember the last time my lawyer, accountant or legistlator was rewarded for doing what they are supposed to do, nor proprerly disciplined for not doing what they are supposed to do. Why do we as a group of physicians put up with this special category of compensation?

207. I don't think these programs improve patient care as much as they streamline and direct administration. The major effects will be to "improve" diagnositic coding and data submission with a more subtle "teach to the test" effect of increasing some, easily quantified, services at the expense of other services which are harder to quantify.

208. They are effective in driving targeted physician behavior but run the risk of negative unanticipated effects.

209. allows both outcome based payment and fee for service autonomy.

210. I have a heard time actually calling these pay for performance in that some of the programs that I am familiar with are not actually rewarding you with higher pay, but simply eliminating that reimbursement cut that under performers receive suffer. The quality payment is simply the portion of the payment that allows them to remain whole. Although, I am familiar with some programs that truly bonus for performance, these are limited. Their permanence will depend on their clinical quality successes and their interactive and political successes with providers.

211. Need to have well define common measures, consensus in the professional community, champions in medical groups, adequate funding, strong buy-in on the methodology, and probably a large regional data base to make it work.

212. The main Pay-for-Performance program right now is Medicare--the rewards seem more targeted at hospital care than office-based care, although that will probably change in the next year or two.

213. If it will improve outcome and patient satisfaction then it should be a part of how we do business

214. The physicians have been asking for rewards based on performance and not just productivity. We have had success rewarding at the clinic level and having the physicians determine how they distribute it within the physician group.

215. Hard to overcome insurers perception that they are already paying for quality health care by providers. Why should we pay more for what they should already be doing? Given the move away from primary care as the gatekeepers of an individuals care, assigning responsibility or credit for a patient's overall care or quality of it is difficult logistically.

216. Use of pay for performance is limited in Canada for most phyisicians as they most frequently are independant contractors. We are looking at introducing this as part of our contract with the hospitalists. It has been used for senior management staff however was suspended this year because of a pay freeze.

217. they will only work if they reward superior care, and will grow income in excess of inflation

218. These generally are asmoke screen to hide overall reductions in reimbursements. Few actually put new money on the table.

219. If instituted game planning will result in disadvantaging a portion of the population to keep results good. The age old argument in philosophical terms between utilitarianism and deontology

220. what are the legal issues involved in setting a program up?

221. A lot depends on who is measuring, what is being measured, how reliable is the measurement what is the differential.

222. They depend a lot on patient compliance. A physician should not be penalized because his patients are unwilling/unable to take medications or follow diet/exercise program as prescribed. A physician in a suburban setting is likely to do better than a physician in urban/rural areas due to factors beyond his/her control.

223. P4P is a tool to be used along with Education, Physician Champions and IT to improve the health care we provide for our patients.

224. Most physicians want to deliver high quality care and are naturally competetive. Physicians are being pushed from too many sides to trust a system that has cut their relationship with patients, reduced their reimbursements and tries to dictate how they practice medicine.

225. Vital to the future of access to quality medical care in this country but risk stratification and proper assignment of individual care outcomes are very daunting details that must be carefully developed for each project. Also the debates between admin and clinical data; and process vs. outcomes measures must also be resolved for each project.

226. The crux of the issue is whether the program is budget neutral or not. If it is budget neutral the program has a chance to succeed.

227. I feel that one of the main reasons behind the pay for performance theory is to decrease money paid for patient care. Performance for pay may be driven to save money by decreasing expenditure for patient care. The newest medication, most updated procedure, and increased access to care usually costs more. The patient and physician are the best decision makers for patient's care. Neither will be the deciding factor on the performance of care. Another middle man will make that decision. If hospitals are paid primarily on outcome of a procedure for instance, they will tend to due low risk cases which result in less morbidity and mortality. The high risk patient who needs the procedure may left without an option to obtain the procedure.

228. Pay for performance will lead to no-pay for non-performance. Pay should follow accountability and outcomes.

229. The idea of Pay per Preformance is excellent. It sets up an accountablility system directly realted to your work.

230. Need to demonstrate that P4P improves outcomes

231. Payment that is performanced based will likely be a part of future reiumbursement. HOwever, this is the latest great thing. There are methodology issues currently and this will have to evolve if it is going to be meaningful.

232. One needs to be careful how 'performance' is defined.

233. Quality is hard to measure and thus hard to reward. Productivity based incentive programs often encourage less than collegial behavior. With pay-for-performance programs, one must be careful as to what is being incentivized. Unintended consequences are common.

234. Pay for performance in the past at my former institution was based on a patient survery with small values of N. As a result, many distorted and useless surveys were used.

235. Actually I think we need to return to shared budgets and reward physicians for bothperformance quality(the incentive in P4P) and decision quality.

236. concept has some merit but issues too complex, sample size etc for small or individual physician groups. Is having some success at system levels

237. Need more focus on education to underachievers and education to all about benchmarks/best practices and how data is obtained/analyzed.

238. P4P needs to be appropriate to the provider, the population, and the health plan. A single plan may not be adequate for all.

239. The devil is in the details. A PFP program that promotes gaming of the system, identifies processes and outcomes that benefit the bottomline over patient care, and/or punishes good doctors providing care to patients with higher acuity illness would be harmful to patients and doctors.

240. It's all about the money. P4P will die when the money dries up. In California, the P4P metrics are changing faster than the healthcare system can follow - and this year a cost based metric (hospitalization rates) is to be added. This is the future of P4P: the employer coalitions driving this thought quality would bring down costs - since it is not, they are shifting to cost reduction incentives.... That is the future.

241. Pay unfortunately seems to be the only stick that will bring about change in providers' behavior.

242. how do we judge performance? number of test ordered and greater reimbursent or quality of care??????

243. Too early to tell

244. The devil is in the details.... if physician leadership is not at the table as indices of "quality" are being determined, then the programs are doomed to fail. It is not going to be difficult to get physicians to see the value of pay for quality care, but if the "end game" is really "expense reduction", then buy-in will be minimal and the system will be gamed by providers. Furthermore, some providers may elect to go non-par with Medicare, further reducing access.

245. The current structure for this is that payers give higher payments for meeting certain "benchmarks" for various diagnoses. It seems to me to be a method used by payers to decrease payments and legitimize it. I do believe better patient care is the end result, but I question the motivation of the payers to instill this.

246. These measures are NOT "PFP" at all, they are reduced pay for not meeting documenation of certain critteria. a real "PFP", which I strongly favor, is extra pay for meeting goals and reduced pay fior missing them.

247. We are participating in a pilot project with our major carrier to incentivize cost-effective Rx utilization and improve quality based on HEDIS standards. There is a degree of fear that "pay for performance" will be misused as just another way to cut payments to docs. (all stick and no carrot)

248. our efforts are focused at the hospital level- bringing it to specific physicians and applying whatever rewards the hospital achieves to physicians is a challenge

249. Our Incentive program is for volume productivity not Quality

250. I believe they focus the physicians and incentivize appropriate behaviors. Ideally the program should raise the bar for all the docs and not create winners and loosers. This would require an expanding pie opportunity rather than a zero sum game.

251. Unfortunately, not evidence based in most cases, and take a narrow measure of outcomes (eg. aspirin given vs QOL preserved or increased life expectancy)

252. It is probably just another way to reduce physician/hospital reimbursement.

253. any discussion must note that the variety of 'programs' is diverse, and it is misleading to lump all programs together. Some may be more punitive than rewarding; some may use the term 'quality' when in actuality the objective is corporate savings, or very strict adherence to 'practice guidelines' which are opinion-based rather than evidence-based. My comments are based on experience and investigation of such programs nationally in a previous position.

254. Concerned that the cost to administer this type of program in the practice will cost more than we are reimbursed

255. We have historically tolerated wide variations in practice under the guise of "the art of medicine". As our knowledge base increases, it has become obvious that there ARE best ways to procatice, yielding superior patient outcomes often with more efficient use of scarce medical resources. It only makes sense to reward those physicians who take the efforts to keep up with best practices and to encourage those who haven't to "get with it"!

256. We will participate in pay-for-performance programs as they are required. For example, we are submitting data which is all that is currently required by Medicare. I expect they will impose P4P soon and our other 3rd party payers will follow. I think if the items chosen for measurement are selected because there is evidence that that is generally the best practice that will lead to improvements in medical care. However, the goal should not be 100%, probably 95% until we get a better idea of the percentage of patients for whom the treatment doesn't apply. Also, they do need to address how performance will be measured when a patient is documented to have 2 or more of the conditions for which management is being graded. I am not aware that there is any evidence based data regarding the management of the patient with multiple conditions. This should be an area that AHRQ should study.

257. It is unfortunate that most of them seem to be set up as a "zero sum game", with winners and losers. So, it is not "new" money that is being added to the program.

258. Pay for perfomance is only appropriate as a model to pay physicians to change their habits - as a rule, they are rarely able to change their habits unless a "carrot approach" is used, and even then the sustainability is questionable. I do feel, however, that PFP has an ethichal problem if payers decrease reimbursement to poor performers to reward good performance; or if they decrease reimbursement for one clincal area to "reward" perfomrance change.

259. If outcomes are achieved then they will be reinforced and expanded.

260. Very important to risk adjust data and to make sure numbers are statistically valid

261. When a physician treats patients and helps them improve their health he/she has to deal with multiple factors outside of the disease process in question that he/she has no direct control over. Not the least of which is the severity of any particular patient's disease process, their compliance with therapy, their body's response to the therapy prescribed, their access to therapy, their ability to pay for the required therapy. Practicing medicine is not like selling widgets where sales dollars can easily be quantified and measured. The subjective factors mentioned above cannot be quantitatively measured but they impact patient care just as much as the dose of the medication prescribed does. There is no way that a "pay for performance" program applied to the pracice of medicine can be set up by the government and / or managed care companies that will be fair and be based on non-subjective measurable parameters. This is just another fad that the federal government is trying so that it can avoid bugeting more needed money to the Medicare system to care for the increasing number of "baby boomers" turning 65 years of age.

262. They tend to be misnamed. They are really targeting outliers in various ways. There are not good substitutes for addressing institutional barriers to better overall service.

263. It depends how the program is crafted. It has the potential of bias agianst good practicing doctor with non-compliant population. in another word the work may be done right but the result may be bad because of other factors.

264. the concept of "better pay for better care" has merit. the challenge comes with identifying the true markers of "better care." this is an ongoing process that will drive even the most stubborn providers towards evidenced-based management of commonly encountered diseases, and even create meaningful reimbursement for time and energy invested in "wellness" activities.

265. They wilkl have to be more equal in the future as the current measures are generally to heavily weighted toward PC.

266. My concern is that too many factors will be evaluated in pay-for-performance and things will be diluted out. In addition, comparing groups to each other as opposed to some benchmark has such narrow margins that very small differences in results leads to large differences in payout.

267. P4P is currently a marketing tool used by HMO's and applicable to only large medical groups. Given health care funding is a zero sum game (at least in California)the moneys to fund the P4P are coming from the small groups and especially the PCP's. Additionally, until integrity can be established in the "performance" criteria, P4P is but an expensive exersize paid by the underpaid physicians forcing them to continue to reduce their participation or increase their churing and unnecessary office testing to survive. The fraud by the payers is perpetuating the fraud by the providers and the Healthcare "system" continues to deteriorate.

268. People need a tangible reason to change.

269. Pay-for-performance programs are sometimes promoted as incentive programs, but really they just mean performing to "our" standard (whoever it is that is setting the standard). It means getting paid less if you do not perform to that standard, not being paid more if you meet the standard.

270. A good approach that requires careful structuring

271. Very difficult to apply to specialty (surgical) medicine. Few metrics for Orthopedic Surgery which can be measured and used to affect behavior

272. We need to move the Pay for Performance from process measures to outcomes (for example drawing a lipid profile on diabetics versus the percent of patients at goal for lipid management).

273. My concern is that the pay-for-performance will be a way to maintain reimbursement for those that 'play,' but to cut reimbursement for those that don't. Given the technical and informational challenges that will be associated with obtaining the data, it will be difficult for all clinicians to even 'get in the game.'

274. We use them to increase encounter data submission (California Model, delegation)with improvement of HEDIS rates and to increase enrollment in our FFS population.

275. We are developing a novel P4P program. It will be consistent with the AMA guidelines for P4P and be based on three broad meausers: 1. Adoption of evidence-based medicine as determined by use of UpToDate.com 2. Adoption of imaging appropriateness criteria as determined by use of the American College of Radiology Appropriateness Criteria website 3. A clinical quality score base on HEDIS measures

276. At some point, reimbursement methodologies will change. At the very least quality measurements will effect payment of service - predictably this will happen when clinical data is more easily and more accurately retrieved from electronic-based data.

277. To adequately utilize a pay for performance schema it will be critical to establish 100% accurate data aquisition on each provider. Without full assurance of accurate measure and input of performance, pay for performance will never be percieved as equitable.

278. I think they are punitive. We are being mandated by the insurance companies, who of course are only motivated by the bottom line, to institute pay for performance. THis will not improve the good doctors' performances, and I doubt will have much impact on the less-good ones. It will only serve to speed early retirement by doctors who are already sick and tired of being told how to practice medicine.

279. incentive not large enough and not funded-half will always be losers. All conditions are not preventable and will drive market to perform only safe procedures with little to no risk. Chronic diseases with risk will be left without access in neighborhood. Children are not a thought in CMS planning

280. Pay for performance will have a much greater impact upon physicians who devote a greater percentage of their time to inpatient care. For those physicians who do most of their activities either in the office or in another outpatient setting such as a surgery center, pay for performance will have very little impact until such time as their office and outpatient service indicators are included. These are oftentimes the same physicians that skew our overall indicator results.

281. We have been gearing up for these programs. Presently no company offers them in our area. We are in hopes insurers will start to offer them.

282. These programs are not about money. They are about setting a national standard for care that every patient should receive at the very minimum. This is not cutting edge, but rather a consensus of baseline expectations. The money merely grabs the attention of physicians and administrators alike

283. My concern is that the performance parameters are going to be designed with different vested interests in mind. For example, the parameters proposed by third party payers may not appear fair to physicians or hospitals and vice versa.

284. many will be really based on utilization and not quality measurements. This will present a problem.

285. Mostly designed by physicians no longer capable of practicing. To achieve most goals requires substantial capital investment (hardware, software, and personnel) not available to a large number of physicians. Could exacerbate the physician shortage we already have (especially in rural areas).

286. SO many prior reimbursement strategies seemed to make sense prior to implementation that were fatally flawed that I am not optimistic this will obtain results desired.

287. Prefer comprehensive data sharing to pay-for-performance

288. I think they are here to stay and will only proliferate. I also think they may finally propel medicine to catch up with the vast majority of other industries in computerization. The fact that most physicians are still using pen and paper is dumbfounding in the 21st century.

289. the relatively modest upside (1-2%) as per CMS will be adequate to change hospital behavior; but will not be enough to result in altering physician actions

290. These programs are in their infancy, but I believe that we are starting down a road that will ultimately dramatically move the physicians' cheese. I believe that it will begin to force hard conversations re: value vs. volume and that it will force review and change in patient care processes and decision-making.

291. Like all new programs, this is based on suppositions that may not hold true.

292. Not the best situation necessarily