|Implemented in this survey?|
Pay for Performance (P4P) programs which give providers a financial incentive to improve quality have widespread appeal, yet initial evaluations show little evidence of quality improvement. Nonetheless, these programs represent a first step towards reforming the current payment system. The Medicare program has recently expanded its P4P initiatives and has the potential to provide this movement with central leadership and direction.
The quality of care is a key concern in the United States. Each year, thousands of medical errors and preventable deaths are documented (IOM 1999, IOM 2001). Only half of adults receive recommended evidence-based care for prevention, and acute and chronic conditions (McGlynn, 2003). Wide variation exists in clinical care by geographic region (Wennberg JE, 2002). Provider payment mechanisms in the United States offer little incentive to improve the quality of care delivered. One recommendation by the Institute of Medicine - "to align payment incentives with quality" - has become the basis for pay for performance (P4P) programs (IOM, 2001). These initiatives provide a financial reward to providers who meet a certain standard of quality (see also previous HPM report on this issue "Medicare "Pay-for-Performance" Initiatives").
Results of early P4P programs
In 2004, Rosenthal and colleagues conducted an extensive survey of pay for performance programs in the United States initiated between 1998-2003 (Rosenthal et al, 2004). The largest of these programs- the Leapfrog Group, Bridges to Excellence, and the Centers for Medicare and Medicaid Services-Premier Inc's Hospital Quality Incentive demonstration program have been described in a previous report (Huynh PT, 2004). In 2007, they again contacted these early adopters to characterize the progress of their P4P programs and evaluate their results:
P4P have had widespread appeal; today nearly 60 percent of commercial HMOs have a P4P program (Rosenthal, 2006). Yet, there have been few formal evaluations of these programs and there is little evidence to suggest that these programs improve the quality of care (Rosenthal, 2005, 2006, and 2007). Only 7 percent of the programs surveyed had been formally evaluated. Overall, 38 percent of respondents reported improvement in quality, 42 percent found mixed effects, and 20 percent found no effect (Rosenthal, 2007). A separate evaluation of the CMS-Premier Hospital Quality Incentive program showed improvement in average quality scores for all five clinical areas (AMI, CABG, heart failure, pneumonia, and hip and knee failure); however, the majority of bonus payments went to the top performing hospitals (USDHHS, 2007; Lindenauer, 2007). Many are looking to the Medicare program to assume a leadership role since its market share gives it the greatest leverage, and commercial providers are likely to follow their lead.
|Medienpräsenz||sehr gering||sehr hoch|
The first generation of P4P programs have not achieved their intended effects, yet they represent a much needed step in reforming the payment system. Further evaluation of current programs is needed if P4P initiatives are to be redesigned to achieve their objectives. Central leadership is also needed to standardize quality indicators and financial incentives; this role can potentially be assumed by Medicare.
|Implemented in this survey?|
Health plans, large employer coalitions, and the Federal government have led the development and implementation of P4P programs. Over the past two decades, health care costs have increased at double-digit rates. These stakeholders have assumed an increasingly large share of the costs, but have not seen a corresponding improvement in quality. Payment mechanisms have traditionally not provided incentives to improve quality; payments to providers are generally the same irrespective of the quality of care delivered (Rosenthal, 2004). P4P programs use financial incentives to encourage improvements in quality and have become widespread over the last few years. Despite the lack of evidence that P4P programs improve quality, these programs are widely implemented in the private sector and the Medicare program has also recently expanded its P4P initatives.
Provider support for these programs continues to be mixed and varies among local markets. For example, the Integrated Healthcare Association's program in California is one of the largest collaborations between health plans, providers, and employers. However, California has a strong history of collaboration and innovation in health care which does not exist in many areas of the country. Plans and purchasers may find it difficult to implement P4P programs in communites where large physician organizations and hospital systems are resistant to these initiatives and have greater leverage (Trude, 2006).
|Federal government||sehr unterstützend||stark dagegen|
|Physicians||sehr unterstützend||stark dagegen|
|Health plans||sehr unterstützend||stark dagegen|
|Patients/Consumers||sehr unterstützend||stark dagegen|
The 2003 Medicare Modernization Act established the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program which requires that all hospitals paid by the Prospective Payment System submit quality data or receive a 0.4% lower Annual Payment Update between 2005-2007 (USDHHS, 2007). The Deficit Reduction Act of 2005 (DRA) increased the incentive to report quality data - in 2008, hospitals will face a 2% reduction in their annual payment update (USDHHS, 2007 and DRA, 2005). Additionally, the DRA stipulates that beginning in October 2008, Medicare will not reimburse hospitals for avoidable complications if acquired during a hospital stay (DHHS, 2007). An analysis of five adverse events showed that Medicare spends approximately $300 million per year in extra payments for these events (Zhan C, 2006).
The DRA also required the Centers for Medicare and Medicaid Services to submit a hospital value-based purchasing plan to Congress in 2007, which will take effect in 2009. Part of its proposal builds upon the RHQDAPU program, and proposes to provide financial incentives to hospitals based on the quality data that are currently reported. It will also expand the quality information available to beneficiaries through the Hospital Compare website (DHHS, 2007).
|Federal government||sehr groß||kein|
|Health plans||sehr groß||kein|
P4P initiatives have thus far not achieved the improvement in quality that was anticipated over five years ago. Several lessons have emerged from first-generation programs.
Despite these design and implementation issues, plans and purchasers continue to be supportive of P4P programs. These programs represent the first step towards reforming the payment system, which is not currently designed to support quality improvement. Many anticipate that Medicare's recent leadership role is a step towards resolving some of the problems associated with first generation P4P programs.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
With some exceptions, pay for performance programs have not resulted in signficant quality improvement or demonstrated a return on investment.
Petigara, Tanaz and Gerard Anderson