Timing is important when it comes to provider pay-for-performance programs, says Ken Kizer, M.D., who is leading the not-for-profit National Quality Forum in an effort to establish a set of baseline best practices for these quality improvement efforts.
A maxim of quality experts is you can't improve what you can't measure and, at the moment, pay-for-performances programs are "all over the board" in their design and operation, said Kizer, president and chief executive officer of the forum. Absent a set of guiding principles, "it will be difficult to compare them and see what's working and what's not."
So at the request of the CMS, the NQF will call a workshop early next year in Washington, D.C., to begin working on baselines in an effort to find benchmarks for the variety of pay-for-performance programs proliferating rapidly at the initiation of governments, employers groups, payers, consumers organizations and physician organizations.
"Standards may be a stronger term than is appropriate at this time," Kizer said of the NQF initiative, given the infancy of the pay-for-performance movement. The Leapfrog Group recently announced there are 86 pay-for-performance programs listed on its Web site, according to Kizer. The business healthcare coalition, with help from the Commonwealth Fund and the Robert Wood Johnson Foundation, only began tracking the plans in late June and started with a list of 77 programs. To see the list, click here.
"What we don't want to do is stifle good ideas or cut off innovative approaches," Kizer said. "This was simply to bring the people together and start the dialogue on what's working and what are the essential building blocks. What we can do is play a role to help find a middle ground. No one knows what's best at this point. We have to try different approaches. The devil is in the details."
"If the programs are going to be successful, there has to be feedback to the clinicians in a timely manner," Kizer said. "I don't know now if we can say what exactly is timely, but we could probably say 18 months isn't. If this program is going to work, timely feedback to frontline caregivers is an essential ingredient."
Other guidelines will address the amount of the incentives, how acuity is handled, and how special populations are to be addressed in the programs, particularly rural and low-income urban core populations.
"How do you do this so that you don't disadvantage already disadvantaged providers?" he said.
Another issue is the level of granularity of the data. Most of the current programs are based on claims data.
"Certainly for the market and this early stage, the (administrative) data is good enough," Kizer said. "But there are myriad opportunities for ways to make it work better. If we had a truly operational health infrastructure, if we were operating from electronic medical records, it would make it easier for everyone involved."
But pay-for-performance and the quality of data, and the sophistication of the information technology systems that produce it, are like the puzzle of the chicken and the egg, according to Kizer.
"I think these two dynamics are related," he said. "They're intertwined."
Kizer has served as Undersecretary for Health at the Department of Veterans Affairs and director of the California Department of Health Services. He also headed California's public health service and its emergency medical service. He is board certified in six medical specialties and subspecialties.
The upcoming workshop won't be the first effort by NQF to help define performance measurements. In April 2003, it endorsed 39 standards for hospital-care quality. The Hospital Quality Alliance, a public-private collaborative, is now using data on 10 of those standard for reporting purposes. Last December, the NQF began an effort to find consensus on a set of standards for quality measurement in ambulatory care. Earlier this year, the organization endorsed 15 standards aimed at improving the quality of nursing care, as well as a set of 21 standards to measure quality of care in cardiac surgery.