The number of physician pay-for-performance programs has almost quadrupled in the past five years, data released last week show, though some in the industry are questioning the value of pay-for-performance programs rapid growth.
Healthcare payers trumpet their use, issuing glowing news releases about the expansion of their programs scope and the millions of dollars in physician rewards theyre dispersing. Meanwhile, government officials, research organizations and physicians are questioning the motivation and methodology of current pay-for-performance programs. In the end, the one industry segment that may truly be happy with P4P are health IT vendors who can persuade providers that their electronic systems are absolutely necessary for the data management that P4P requires.
The data, from healthcare informatics group Med-Vantage and the Leapfrog Group, projected there will be 155 P4P programs in place this year, compared with only 39 in 2003.
Yet a report from PricewaterhouseCoopers released earlier in August found some P4P flaws. Looking at 10 different pay-for-performance programs, the researchers found that they used almost 60 different physician performance indicators; that no one indicator was used by all 10 programs; and no two programs rewarded providers the same way.
Pay-for-performance programs can be an important tool to link payment to quality, the PWC report stated, But the wide variation in program structures, performance metrics and rewards structures mutes their potential impact.
Along with the plethora of differing measures, the PWC report noted that the physician rewards offered were generally too low to make a significant difference.
I thought the report by PWC was pretty much on the money, said Francois de Brantes, national coordinator for the Bridges to Excellence physician reward program.
Bridges to Excellence announced last month it now has more than 100 employers and health plans working in 19 regions participating in its physician office, diabetes-, cardiac- and spine-care programs. Physicians have to know If I do this, Ill get a positive hit from multiple parties, de Brantes said.
Meanwhile, physician-ranking programs under consideration for use by insurers Aetna, Cigna HealthCare and UnitedHealth Group have come under scrutiny by New York State Attorney General Andrew Cuomo, who expressed concern that the rankings may be used to steer patients toward less-expensive rather than higher-quality providers.
In an e-mail, Aetna spokeswoman Cynthia Michener said Aetna is fully cooperating with the request for information, is committed to transparency and is reaching out to medical societies to address physician concerns about reliable data.
Some in the industry, physicians in particular, view pay-for-performance and other performance ranking plans as merely a way to pay them less. Former American Medical Association president and Joint Commission board member Donald Palmisano expressed support for Cuomos investigation. Cuomos concern is a valid one, said Palmisano. Its been frequently stated that this (P4P and physician rankings) is more of a rationing plan for health plans to make more money.
Palmisano, a New Orleans surgeon and attorney who now operates Intrepid Resources, a risk-management, patient-safety and claims-review consulting service, expressed disdain for the whole concept of pay-for-performance. First off, a physician has an ethical and fiduciary responsibility to do whats in the best interests of the patient, he said. I think its insulting to think that giving me an additional amount of money will make me do what Im supposed to do.
And while Palmisano criticized the concept, the American Board of Internal Medicine last month issued a news release trumpeting how the Blue Cross and Blue Shield Association, Cigna HealthCare, Humana and WellPoint were incorporating the boards maintenance of certification programs into their physician reward programs.
Although Aetna wasnt signaled out by the board, the company noted that its measures are developed from standards consistent with those created by the American Heart Association, American College of Obstetricians and Gynecologists and the CMS.
In addition, on Aug. 24, Blue Cross of California (a subsidiary of WellPoint) announced that it was rewarding 126 physician groups a total of $69 million in bonuses for performance in 2006. About a week earlier, Blue Shield of California announced that it distributed $31 million in bonus money.
In an e-mail, Michael Belman, medical director for clinical quality and innovations at Blue Cross of California, said rewards continue to grow and have increased from the initial payout of $25 million in 2003. He added that the program is a part of the Integrated Health Associations pay-for-performance effort involving a collaborative of 200 California medical groups and seven health plans (including Blue Shield of California), and that data acquisition is coordinated, and we use the same quality metrics across the entire set of provider organizations so in this program we have minimized the administrative burden.
We do believe some IT building blocks have to be put in place to reduce the burden on providers, said Sam Muppalla, chief operating officer of Portico Systems, a Conshohocken, Pa.-based software provider for health plans.
For de Brantes, the key is to have doctors begin their own systematic collection of data that will provide them with internal feedback that is plan agnostic.
That way they can look at the data for all their patientsnot just one plan at a time, he said.
Hindy Shaman, a PWC director who participated in the creation of the P4P report, said wider IT adoption would pave the way for standardized measures, make it easier to validate physician data, and reduce the administrative costs of P4P.
All the different measures are just a morass for people to deal with, and the concern is that people will just throw their hands in the air and give up, Shaman said. It doesnt mean that the solution itself is wrong. Its just that were going about it the wrong way with everyone inventing their own yardstick. It doesnt need to be this hard, and were doing ourselves a disservice by having so much variation.