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Pay for performance
Physician incentives promote best care, benefit patients
By Gail Amundson, M.D., F.A.C.P.
Minnesota Health Care News May 2006
Despite the life and death drama you see on the TV show ER, for most patients, simple things can make a big difference between great health care and not-so-great health care. Consider Jim: he's 45 years old and has diabetes. A phone call from his doctor's office saved him time and extra office co-pays. But this added interaction is also helping him steer clear of serious medical complications of diabetes like blindness, limb amputations, heart attack, and stroke. The caller, a medical office assistant, asked Jim to come in early for some critical lab tests, so that he and his doctor could discuss the results in person. The lab tests showed that Jim's cholesterol and blood sugar had begun to inch upward. His doctor adjusted two of his medications and gave Jim a phone number to enroll in a class that would show him some simple changes in his daily routine he could make to stay healthy. Lately, Jim's lab tests are showing normal results. Hes feeling better than he has in a long time and he doesn't have to see his doctor as often.
Jim probably doesn't know it, but he's the beneficiary of a program to reward the kind of care that gets great results. The idea behind the pay-for-performance (P4P) program for physicians is similar to performance recognition in other fields such as education: define success, measure it, reward it.
The quality chasm
Most patients probably assume they are getting top-notch care, but recent studies show that's not the case. In fact, a landmark report in the New England Journal of Medicine (2003 McGlynn, et al) found that Americans get the care they should only about half the time. For instance, researchers found that many heart attack patients did not get a low-cost drug called a beta blocker even though it greatly reduces the risk of a second heart attack. They also found that patients suffering from chronic headaches get too much medication, but they don't always get lab tests that check for neurological problems.
For many products and services, you get what you pay for. If you want better quality, you expect to pay more. However, we're learning that more expensive health care is not always better health care. A study published last November in the journal Health Affairs (Wennberg, et al), found that Medicare pays some California hospitals four times more than others to care for similar patients. The more expensive care actually resulted in lower, not higher, quality and lower patient satisfaction too. Growing evidence like this is one reason the Institute of Medicine of the National Academies, a nationally recognized nonprofit organization specifically created to provide science-based advice on matters of biomedical science, medicine, and health, is recommending that health plans and other payers of health care reform their payment policies to reward better care.
What is quality health care?
In order to pay for quality health care, we must be able to define what it is. One key advantage of pay-for-performance programs for both doctors and patients is that the quality measures are based on best practice guidelines. Best practice guidelines are written statements that present the best, standard way to treat or care for a specific health problem based on an objective review of the best medical evidence and other knowledge. Best practice guidelines is part of an important new trend called evidence-based medicine, which first appeared in the medical literature in 1992. Evidence-based medicine lets doctors know what works and what doesn't. It lets patients know when they are getting the best care and when they are not. It lets health plans reward quality care and not pay for poor care.
Critics of evidence-based medicine worry that best practice guidelines will dictate treatment and limit doctors' and patients' choices. In fact, good doctors use both their individual clinical expertise and the best available external evidence. Both strategies are necessary to properly treat a patient because sometimes even excellent evidence might be inappropriate for an individual patient. But without best practice guidelines, a physician's practice can quickly become out-of-date and patients don't get the best care available.
How pay for performance works
In the past, doctors often hesitated to talk to their patients about smoking because it wasn't part of their routine and many thought some patients would be offended. Now, most physicians routinely ask every patient about tobacco use, advise those who smoke about the importance of quitting, and assist patients who are ready to quit. What changed? Based on evidence that physician intervention is very effective and increases patient satisfaction, health plans began to offer rewards to physicians for asking about tobacco use at every patient visit, and physicians started changing their practice.
It didn't cost a lot of money or take a lot of time, but these simple changes have contributed to a dramatic drop in smoking. Among HealthPartners members last year, 18 medical groups asked 95 percent of patients about tobacco. As a result, patients are quitting in record numbers. Five years ago, more than 25 percent of HealthPartners members smoked. According to the lastest records, tobacco use is at an all time low of 15 percent, and those who do smoke are taking care to protect their children from secondhand smoke. In 2000, one in four children routinely breathed tobacco smoke. Now, that number is down to fewer than one in ten. That's remarkable success.
In addition to rewarding improved care, pay-for-performance programs reward improved efficiency. If your doctor is prescribing more generic drugs than brand-name drugs, one reason could be pay-for-performance incentives. The average brand-name drug costs three times more than its generic alternative, even though they are equally effective in most cases. Since HealthPartners began rewarding clinics for prescribing generics when appropriate, generic drug use has increased to nearly six in ten prescriptions and that has reduced drug costs by $62 million.
What gets measured gets improved
HealthPartners was one of the first health plans in the nation to introduce pay for performance. That was in 1996. Ten years later, there are more than 100 private pay-for-performance programs in the nation, according to a survey by the Institute for Health Policy Studies at the University of California, San Francisco. Even the Centers for Medicare and Medicaid Services, one of the biggest health care payers in the nation, recently announced pay-for-performance initiatives.
The most dramatic success story has been with patients like Jim. In total, every year 320 HealthPartners members with diabetes avoid complications that lead to blindness; 120 patients avoid having a limb amputated; and 80 patients are spared a heart attack. By rewarding best quality health care, the value of health care for patients is heightened. Improved health, higher patient satisfaction, fewer medical complications, and reduced medical expenses are just some of the benefits. For patients and their families, a higher quality of life is priceless.
Gail Amundson, M.D., serves as associate medical director for Quality Improvement at HealthPartners.
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