Pay for performance: We’ll be better off

Chlamydia screening is another example. By implementing it in a more wholesale fashion, screening becomes easier to perform. Value judgments about a patient’s lifestyle are no longer necessary, and patients accept the screening as part of a larger program rather than as a by-product of their “high-risk” lifestyle.

The bottom line: If appropriate measures are included, we should be able to change clinical behavior and improve patient care.

Bonus could be bigger than you think

Rewards can be substantial in P4P programs. For example, they might consist of a bonus check delivered to the practice once or twice a year, or enhancement of the fee schedule by a certain percentage for the following year. The bonus check, too, may be based on a percentage calculated on top of total earnings from that payer during the time period measured. The precise enhancement possible is proprietary information for most plans, but generally ranges from 0% to high single digits.

That may not sound like much to you. But let’s assume you can earn up to 7%. Let’s also assume you have annual collections of $1 million in your practice and a particular payer is responsible for 25% of your revenues. That 7% would total an additional $17,500. If all your payers sponsored P4P programs and you did as well across the board, that would result in more than $70,000 in enhanced revenues—right to your bottom line.

Who’s looking out for ObGyns?

Many organizations are focusing on P4P, but the activities of the American College of Obstetricians and Gynecologists (ACOG) are most relevant. ACOG has been developing performance measures and plans to incorporate them into new practice bulletins. So far, 21 measures have been developed and are being beta-tested. Approximately 40 more measures are under consideration. The biggest problem to date: The data needed to evaluate performance are not readily available without chart review.⁶

How data are obtained is a rate-limiting step at this point—and perhaps always will be. Chart reviews are highly inefficient and costly, and often rely on extrapolation of results from a limited sample to the whole universe of charts. Sampling errors may be unavoidable.

Large groups may have a technology advantage if they can afford sophisticated practice-management systems—or even EMRs—that make it easier for them to prove compliance with a P4P program. Smaller groups would face increased costs for “mining” their own data manually, or find it necessary to rely on data developed by the P4P sponsor.

One of ACOG’s chief concerns (as well as that of other physician-friendly organizations) is design of a P4P program that can be easily implemented in any size practice.

EMR use remains limited

A recent article at www.amednews.com cites a 2003 survey showing that only about 25% of physicians have access to EMRs.⁷ A more recent article from Health Affairs puts that figure below 20% and identifies barriers to EMR implementation.⁸

The important point: Until we all use EMRs in our practices, P4P programs must be designed to work within the limitations of our data capabilities.

The Accreditation Association for Ambulatory Health Care’s (AAAHC) Institute for Quality Improvement has developed principles/guidelines for P4P (see www.aaahc.org), as has the AMA, with agreement in many of these areas.

Will anything bad happen if you do not participate?

In an age when “consumer-driven health care” and “transparency” are becoming everyday mantras, a practice must stay ahead of the curve as much as possible and not be left on the platform as the train pulls away. Make no mistake, part of the P4P rewards system in the future will be public recognition, which will help payers drive their members to the “better” doctors. A refusal to participate in a P4P program might initiate a downward spiral from which it may be difficult to recover.

I don’t mean to imply that the move to consumer-driven health care is necessarily a bad thing. After all, ObGyns are frequently chosen by patients on the basis of word-of-mouth recommendations. I’m simply saying that, if data about us are going to be available for members to peruse prior to their selection of a provider, we should try to control that data as much as possible. It is vitally important that measures used to qualify us as “high performers” are, first of all, meaningful and, just as important, accurate.

A major risk is that a focus on process goals interferes with our attention to outcomes. What good is it if every patient undergoes cervical cancer screening if we don’t properly triage abnormal results? P4P should not distract us from what should be our raison d’être: giving the best quality care we can, leading to the best outcomes.