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1. They are an inevitable rising tsunami that will overtake us due to the strong involvement of third party payers created by the underlyling impetus from Leapfrog and other quality imperatives.

2. Evidently did not work in industry. Too comlex for an equitable system to reimburse physicians. Let frre market competition determine who get paid what.

3. Much of what is being measured is highly dependent on patient behaviors. Physicians are not in direct control of what patients do, and should not be held accountable for patient behaviors.

4. quality measures not sufficiently developed to support robust programs for most specialties yet, so presently for the most part limited to PCPs. efficiency based measures not yet ready for this application.

5. Design and implementation critical as is organizational support so the physician can be successful.

6. This will become more of a standard when standardized outcome data through electronic databases become more developed.

7. The concept of P4P is correct but we have a long way to go before all of the unintended consequences are addressed and before the true value of P4P is achieved. To achieve the desired aims, P4P programs must remain rooted in quality measurements and only later, after achieving a critical mass of credibility, should cost-efficiency measures be added.

8. It is sad to see some HMOs to put the programs (carrott) out there and then look for every loop hole to deny payment.

9. Because medicine is not a science but an art, these programs are often simply GIGO. Real patients have multiple problems that practice guidelines are not suited to. There can never be large enough numbers of patients with real combinations of illnesses to enter into trials to find the "best practices" in real clinical medicine. This is logical but does not have hte emotional punch of a simplistic flow chart and checksheet.

10. In the process of implementing fro 140 physician group. PFP increases physician buy-in to the goals of the organization which imporves billing and efficiency generating more income which can be distributed more equitably. Hard workers are rewarded and others are incentivized. Based on RVU data, anticipate 90% plus physicians will increase their wage and 5-10% will not - which in part means that they are not aligned ("Good to Great")and may need to get off the "bus".

11. The biggest concern is to make sure the data is being accurately collected and measured

12. It's hard to keep these programs from being at least a little subjective. In emergency medicine--if you're looking just at RVUs per hour, this inevitably leads to cherry-picking.

13. Do you intend this survey to apply to Pay for Performance for physicians only or hospital performance, e.g. the Medicare program for hospitals. My answers apply to the hospital not individual physicians.

14. One Year Wonders

15. I think some other kind of incentive should be used in encouraging quality care.

16. The performance programs we participate in have easy to reach goals which are important to the health plan for their reasons, but do not confront what physicians percieve as quality.

17. The real question is in the pay and the performance. All too often, some national guideline is chosen and then applied across an entire population of patients(a population not appropriate for that guideline) creating incentives for care that are not good care.

18. I believe they will be used to gain performance improvement that is much need by ensuring evidence based quality medicine is practiced. I am concerned they may be used to decrease pay by making payment expectations unreliable

19. This is one of the few ways available under the current arrangements in the U.S. for encouraging good chronic care and good care that crosses transitions points, e.g., from hospital to ambulatory care and back.

20. The quality measures for primary care and cardiology are pretty well established in several disease states. However, there are fewer EBMs for specialty care. How can a payer ask them to participate? Perhaps CMS can reduce payments for procedure-based activities to fund the increased quality demands for primary care?

21. performance metrics must be chosen carefully and based on evidence-based standards widely accepted

22. There will be a dumping of non-compliant or difficult patients in order to have physicians performance appear good

23. Another ruse by big insurance to extract more work from physicians for the current slave wages!

24. Current mechanics of most p4p programs are inconsistent and the data on which the rewards are based are generally claims based and inherantly inaccurate. the best way to get accurate data is from chart pulls, which is obvioulsy labor intensive. the ultimate best way to drive P4P programs using clinical data is to create some method for heavy financial incentives to enhance providers health information systems. The government and commercial payers need to ramp up such financial incentives.

25. If a group of physicians has been good citizens and responsible physicians all along, then the benefits and advantages of P4P are a bit difficult to realize.

26. It would require a mature electronic medical record to be able to gather physician specific data rather than the attending physician or PCP being targeted as the responsible physician

27. very difficult to do right. the more we use standardized measures, the more effective it will be.

28. In California the P4P program is working very well with significant improvement in outcomes.

29. Putting a significant amount of reimbursement at risk seems to be really the only way to get most physicians' attention regarding improving outcomes, improving patient satisfaction and complying with accepted guidelines.

30. Difficult to establish for commercial population in open access HMO or POS product who do not have to designate a PCP. Shouldn't there be a program to incentivize patients to be more compliant with their treatment regimen?

31. These programs are bait and switch. Soon they will be we won't pay or will pay less for failure to perform. Down side: it will penalize creativity and appropriate deviation from the presume standard of care.

32. The concept is good, the devil in the details. Pay for performance is moving fast, far in advance of validated quality indicators and the processes involved in evaluating results and the reasons behind them.

33. This is a juggernaut that is coming, and we must be prepared. I tend to believe that with better electronic records and easier and less costly ways of auditing it is probably here for a longer time than some of the other fads which have come and gone, because of lack of valid tracking. Whether it will prove to be fair remains to be seen, but one must clearly recognize that payor vs provider perspective will always influence this perception.

34. Not enough solid data yet concerning generalized applicability of the concept.

35. I think the term "fad" has more negative connotation than I would choose. I would view it as likely being a transitional structure. Currently, there are major missed opportunities in health care for prevention and managment of chronic diseases. Right now we need to put financial incentives in place for physicians to fix these problems. The majority of the issues are process issues that will take some time and money to work out. Once new processes are put in place, this care will be provided at higher levels, and basically automatically from physicians. When this starts to happen, it will be taken for granted, and pay for performance will no longer be necessary. With the latest article in the Annals of Internal Medicine from August 19, it is clear that the things that are being measured do likely have an impact upon the health, well-being and mortality of our patients. We need to perform them. We need pay for performance to help fund building the structures that will allow us the higher levels of performance.

36. Our PHO, which is the contracting arm for both our physicians and our hospital system, signed a contract as a clinically integrated entity with BC/BS last year that is a unique PFP contract. It is a five year contract with annual rate increases and decreases tied to clinical performance target that the physicians have agreed upon.

37. We believe we must participate and set the criteria for gastroenterolgy and are very intereste in the insurance companies criteria that may already be out there. We need to do this however beieve in the short term and the long term this will again only be used to reduce payments if possible to all physicians (ie give 1-2% to the top 20% and remove the same if not more from the remaining 80%. Interesting comment I heard, you are all great and do an outstanding job of care, we just now have to work on "costs" to the system. If you show what physicians do poorly and include them in the process, they will all move to the highest level without much cajoling. We have seen this happen numerous times in our local hopital. The key is just including them in the process.

38. Our current system rewards volume, not quality The only way the system will improve is if we align the incentives correctly.

39. Expect that performance standards will be established with time and providers will be penalized for not attaining the standard.

40. Performance based pay works, just ask anyone on salary vs. hourly. It's easy to make more with overtime.

41. Incentivizing the physicians results to better quality of care. Better quality improves patient-doctor relationship, and increases participation of the patient with his care. Preventive care and patient education foster healthy lifestyle, thus decreasing the risk of hospitalization, which is cost-saving to all.

42. In California, I perceive bias depending on what socio-economic community the group serves. I have become aware of a North-South differential in HMO capitation which favors Northern CA groups which can offer open access to specialty care, generally a patient satisfier.

43. P4P in California is well designed program that elicited input from employers, health plans, and physician organizations prior to implementation. It rewards groups based on quality, service, and information technology measures. It has help create a stronger business case for quality, and has promoted accountability for health care outcomes.

44. Systems to measure quality are lacking and expensive. Outcome measures are impacted by patient factors that may be beyond the control of the provider. Deciding on who gets paid in P4P is an issue - the provider, the department, the hospital or clinic, the system.

45. I think reimbursement systems will continue to emphasize excellence in care, though the criteria and standards will evolve.

46. Physicians should support this concept as a way of improving the performance and accountability of their profession.

47. Pay-for-performance programs still allow a portion of the medical community to practice sub-par medical care. Why would we structure programs that leaves this void? Why not work to implement a STANDARDIZED, national electronic health record that could be used as a tickler to remind patients and physicians about preventative care, medication interactions, new care strategies, evidence-based medical protocols, etc.?

48. In California there is an unfair advantage held by sophicated well-funded medical groups. As we move to administrative data only for paid incentives, groups unable to collect this information electronically will be disenfranchised. To my mind, this creates an uneven field and becomes an incentive for technology rather than quality of care.

49. The value is in the details. Programs have to be linked to actionable data so improvement is stimulated. Paying for incremental improvement is valuable as well.

50. I suspect that they will not truly be fair

51. Criteria for the program is important. For example, there are issues relating to quality care which are not part of the HEDIS listing. Physicians should be rewarded for quality care parameters not listed in the HEDIS list.

52. Society of Thoracic Surgeons have the best data over twenty years and their performance in improving the morbidity and mortality of coronary artery bypass surgery is impressive but the reimbursement keep going down.

53. If they are concise, agreed upon by both parties, verifiable by both parties, they can be effective. We have had such a relationshionship with a few payors. It has been profitable to both as we have shown them we save them money by practicing cost effective, good medicine.

54. these will require resources and process management which might make them a challenge to administer.People learn to game the system and pay for preformance may become like today HMO

55. I think pay for performance is necessary to provide legitimate incentives for physician retention while at the same time aligning quality initiatives.

56. MDs don't seem to like them

57. Need to be tailored around generally accepted quality measures with elements also included relating to cost effective care

58. Money to pay for perf has to come from those who don't meet goals. may tend to cause MDs to only accept pts who don't have conditions that are in program, or hurt those MDs who still take all comers and "barely miss" the goals.

59. The challenge is defining the performance and quality improvment. Clearly rewards for volume through the office or RVU's per month work, but the real issue is the quality of the outcome for a given patient. Defining the clinical outcome is the slippery slope. I think physicians are going to resist being told what they get to create for fear of being judged less than capable. So, the tendency will be to set the bar lower that what could be achieved. Or, to just say that there is too much variability to assign expected outcomes - they will dodge the whole issue. On the other hand, the lure of money may open some minds. Under these quality improvement expectations there has to also be a CME infrastructure to educate practitioners on what they get to know and how they get to behave to create the expected outcomes. So, a complex challenge that really deals with the heart of why we do medicine. The real question is the intent in implementing such programs. Like managed care, if is done purely for economic reasons, and the patient is left out of the equation, the dark side will prevail and the concept will ultimately fail to get traction on a wide scale.

60. Standardized measures difficult to develop; systems may fall in and out of high performing group from year to year; will adverse selection cause deterioration of performance metrics? It's a noble concept in some ways, a bit crass in another (paying more for what should be a standard. It should be tried, even though it's long term viability remains uncertain in my mind.

61. Need to be carefully crafted to take into consideration risk adjustment, volume, etc.

62. We'll see systems and doctors lerning how to "game" the system

63. Pay-for-performance will soon become a standard for even "participating" in a given network or with a health plan. Soon, the ability to access membership will be the "pay" rather than a simple dollar figure...

64. Physicians have so many things on their plates from so many different health plans. How else do you get their attention for your health plans HEDIS scores, ER performance, generic, etc. P4P for office staff who do the "heavy lifting" with the doc also is helpful.

65. If done right (i.e. using the AMA principles) this is a better way to pay than the way we're paying now, which is the for the same care, whether good or bad.

66. PPF to be effective needs electronic medical records as a minimum, full EHR to really access well. A straight side-by-side comparison without awareness of practice demographics innately skew better performance to populations with insurance. A practical example of this is a community health center patient with no money being treated for an exacerbation of inflammatory bowel disease. The clinician evaluates appropriately and prescribes appropriately by guideline but existing indigent care drug programs provide chronic care drugs. There is no plan for same day, hospital avoiding drug provision for the non-entitled patient. The same patient in a health plan or with health insurance evaluated similarly is likely to comply with guideline treatment. The outcomes are different although clinician service is the same. I expect the PPF to fad due to the current low per centage of ambulatory practices with accessible electronic patient data. The concept is correct, the means to apply is not in place.

67. Medical care bundling as an expense continues to taken apart more day-to-day by 3rd party payors. Fully expect that reimbursement will be production-based no matter how payor initiatives migrate in the future.

68. Most are poorly planned & designed.

69. The physicians and Licensure Boards must be willing to look at how they practice medicine and how they think that it should be practiced. This should then be started in medical school.

70. Rightnow they seem to be a substitute for paying physicians well for what they do. The trend is to pay low rates for FFS, then withold a pot of $, and put a small portion of it into the pay for performance

71. Any incentive system can be "gamed", so it will be difficult to tell if these programs are effective until they are in place for some time.

72. These programs represent a nieve approach. They are not based on a scientifically proven methodology although some parameters represent current clinical guidelines. The current design causes a Hawthorne Effect based on that which has focus, not true outcomes measures. They fail to accomodate for comorbid conditions and as a result may lead to increased adverse events as individuals strive to attain the "pot of gold". I am aware of individuals and institutions providing unnecessary care in a shotgun approach to ensure they qualify for these "bonuses"... and frequently the bonus is merely a restoration of what should have been reimbursed in the first place. These plans usually originate from payers without real design by those who actually provide the care. In short, it's mostly a sham due to the lack of a sophisticated model based on profound knowledge of the processes that result in the desired outcomes - and outcomes science currently in too immature to provide meaningful vigor and reliability to make any of this meaningful. As currently configured, it represents a threat to improving quality of care, and make result in increased patient risk.

73. Must be win win. You cannot have winners and losers. Small financial rewards tied to recognition is more powerful than large $ rewards for cost savings. Physicians must be engaged in picking measures and targets. Quarterly payouts better than delayed payments. Data screwups need to be addressed and payed out in favor to the physicians. Measures should be yes no or based on hedis. Avoid control of disease measures especially best control. ex; A1 Hg control below 9.0 not 7.0

74. in many specialties is very difficult to measure and compare performance

75. 28 years experience in equal sharing of profits is unfair to "genetically predisposed" hard workers. The chronically lazy members quickly discover how to game the system to give them the best of all worlds: more money annually than they produce (out of their partners pockets), less work and stress than the hard workers, and as a result, less malpractice exposure (fewer patient encounters per year). I'm a radiologist, presently working locums whil trying to start an imaging center. A frequent recurring observation voiced to me at various Radiology facilities over the past 3-4 years is that new young Radiologsts coming out of training are demanding large salaries to start. Once they arrive, the facilities (usually hospitals or imaging centers) discover that the new physicians manage to do much, much less work than the typical radiologist. "Generation-X is finishing medical school and residency."

76. In the VA system, the increase in pay is not significant. However, the recognition among peers and the desire to improve does make a difference in documentation of behaviour change. Practicing clinicians, MD/DO, nurse practitioner/PA believe in the electronic medical record, (CPRS) and its ability to quatify changes in care. The real problems of using the care algorhythms as evidenced-based best practices protocols still could become etched in stone stiffling research in patient care and using clinical judgement by clinicians continues to be a dilemma for thinking physicians and nurses.

77. I have developed and implemented a quality and service payment for primary care physicians in AZ. The physicians did not have much problem with looking at their data and where they could improve, the problems occur more when they see the initial data and do not feel they are given enough time to try to improve before they are penalized.

78. I think this is just one more way to "control" the work of physicians. It may bring you a little more money at the beginning but then everybody will play the same game and it will become more "punitive/controlling" than what we have now. The amount of money available for Health Care has not suddenly increased. There would be some savings from achieving good performances, on the long run mainly.But I expect those "savings" won't necessary increased physician reimbursement. How many other "liberal professions" are controlled that way? It would be difficult to collect the data unless you have EMR and even then you have to be aware of the different reasons certain parameters could not be met that are not physician related. So, the way the data are collected is also very important. You have to consider "shared patient" between different providers of a same practice and even from different independent practices.Physician may order a test or consult to meet established parameters but patient might not be compliant(even after good explanation of the reason to perform it); this is not fair for physician not to be "credited" for it.

79. They encourage high volume, low quality medicine in some settings, e.g. the hospitalist (inpatient medicine) setting. They are expedient for enhancing hospital revenues, but increase risks to patients by detracting from good quality medical care.

80. GOOD IDEA BUT THE EARLY VERSIONS THAT I HAVE SEEN SO FAR TEND TO FOCUS MORE COST ISSUES AND DO NOT IN MY OPINION ADEQUATELY RECOGNISE THE COMPLEXITIES OF INDIVIDUAL PATIENT CARE.

81. The problem with pay-for-performance programs is that they are liable to discourage doctors from taking on the more difficult cases. These programs will move adoption of EMRs forward, and that will improve the standard of care as the programs get better at identifying quality issues for the doctor to address. Unfortunately, the costs of incorporating an EMR are still prohibitive for the small practice, and it would be problematic if reimbursement to those physicians started to fall due to failure to comply with pay-for-performance standards.

82. they need to focus on outcomes not process It is embarassing to have to be paid to improve quality...our industry has been lax

83. In my area of country P4P is very early and the means to measure and reliably report performance is very crude.

84. need better alignment between providers and payors for performance; until data can be easily collected (ie., EMR) it is a challenge to obtain realtime data that is actionable

85. well designed programs will encourage physicians to pay attention to performance goals and improve quality. The question is whether these are the right performance goals and how to measure physicians whose patient populations make it more difficult to achieve the goals.

86. The concept of hospitals giving physicians "privileges" to work in the hospital, and then requiring uncompensated call for the hospital, is an example of leveraged behavior. However, the leverage is decreasing, and many physicians are choosing to not work in the hopsital at all, and won't consider frequent call coverage.

87. I am concerned that pay-for-performance programs will cause considerable conflict of interest.

88. Too soon to know how they will work in reality, but far too many physicians in denail about their pay changing based on these programs

89. Risk that cost of participation is more than reward.

90. The money we get really goes towards the extra work it takes to document the care we already deliver. We will have to see if our rates of generic medication prescribing are affected by P4P.

91. No Panacea. The severe structural problems inherent in our disjoinged FFS payment system are much bigger obstacles to signficant quality improvement. Pay for Performance can help, but I think it will have a marginal impact.

92. Pay for performance in our clinic has the risk of docs working in tandem cherry picking the higher reimbursible charts. Trying to account for patient volume and charges is more cumbersome....we are probably going to continue to use multiple metrics to support annual increases.

93. It is hard to measure the quality of care provided to a patient.There are also patient and social factors that affect the performance but are not under tghe control of physicians. Also, P4P may cause physicians to avoid treating complicated patients for fear of lowering their performance.

94. Definition and Measurement of Numurators and Denominators as well as sample siza are major issues.

95. measuring performance goals are very difficult-need better metrics for evaluation

96. This is yet another attempt to control healthcare costs initiated by those who do not know how to get at the basic issues.

97. "Pay for Performance" is a term that is cost focused and diminishes the focus on quality and optimal outcomes. In many instances, the payer databases upon which physician performance is "graded" are different from each other. There should be an entity that collates data from all payers and allow this non-payer database to become the source from which physician ratings are based.

98. pay for performance is the traditional way we physicians have been paid and I don't see it going away. HOwever, quality objectives seem to be neglected in this system because quality is not a "paid" service.

99. This is a popular government strategy of holding a gun to our head and yelling "innovate!" As long as there are quality consultants, as long as quality is "proprietary", as long as innovations are considered "trade secrets", the poorer hospitals will be penalized. Why is it that I can access immediately the latest research on vaccinations, drugs, or surgery, but the details of how to implement these life saving therapies is only available in $1800 IHI seminars? As unAmerican as it sounds, maybe we should pay the hospitals who are not meeting goals more so that they can meet goals. If poorer, minority, rural hospitals are below standards, they are the ones where we could save lives. Why waste our money on the hospitals that are already meeting the goals? They obviously don't need it.

100. They are the most recent scam to be perpetrated on physicians. Agree to them at your own peril. All physicians will regret their participation in any such program.