Pay-for-Performance

V. Key Issues: Population Health >> H. Quality/Satisfaction >> General Approaches >> Pay-for-Performance (last updated 5.2.18)

Lead Editor: Dana Beezley-Smith, Ph.D.

Also see: Accountable Care Organizations and Patient-Centered Medical Homes 

Overview

Pay-for-Performance (P4P) schemes involve awards to health care providers who reach particular goals. Most P4P rewards are delivered over and above traditional fee for service or capitated payments. However, increasingly P4P programs are withholding a percentage of traditional payments for failure to reach quality and cost benchmarks.
Quality goals have in the past been consistent with the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) quality markers, reflecting structure, process, and outcome.
The 2010 Affordable Care Act (ACA) relies upon a number of P4P incentives to reduce the cost and increase the quality of health care delivered to individuals covered by both public and private insurance. The ACA’s P4P programs aim to eliminate the traditional fee-for-service (FFS) system, as advocates believe this system leads to overuse of testing, procedures, and other medical services.

• Pay-for-Performance (P4P) Whitepaper. “As the landscape of healthcare continues to make this shift, health plans, health systems, and individual providers are being asked to change the way they provide care to align with the incentives of these new programs. Under these new models: Providers are shifting to a proactive, population-based care models; Health plans are paying providers based on the measured risk of their population and/or the quality of care they are rendering. Although the ultimate goal of all stakeholders is to improve care while reducing costs, there has been resistance by both parties to change.” (Arcadia Healthcare Solutions, 5.14.14)
• How Insurers are Adjusting Payment to Medical Providers “Commercial insurers are ditching or at least tweaking the way they pay medical providers, according to a report out Tuesday from the group Catalyst for Payment Reform. For years, commercial insurers as well as state and federal governments have paid doctors and hospitals under what’s called fee-for-service. To many in the healthcare world, fee-for-service is seen as one of the key drivers behind the run-up in healthcare costs, because it offers providers a financial incentive to provide extra services that may not be needed… Rosenthal says, based on her research, alternatives to fee-for-service can reduce the volume of services by as much as 20 percent. Rosenthal is quick to add that there’s no great evidence yet on the effectiveness of any of the alternatives.” (MarketPlace Health Care, 9.30.14)
• Providers and Insurers Jump on ‘Value-Based’ Pay Bandwagon. “In another sign that the days of fee-for-service (FFS) medicine may be numbered, an alliance of major health systems, insurers, and other industry players announced its formation yesterday as well as its goal to put 75% of its business into ‘value-based payment arrangements’ by 2020. The group’s ultimate goal is to improve patient outcomes while lowering costs… On the provider side, HCTTF includes Partners Healthcare, Trinity Health, Ascension Health, and Dignity Health. Of the nation’s top 15 health systems, six belong to HCTTF, according to a news release by the group. The four health insurers in HCTTF are Aetna, Blue Shield of California, Blue Cross Blue Shield of Massachusetts, and Health Care Service Corporation, which operates Blue Cross and Blue Shield plans in five states.” (Medscape Medical News, 1.29.15)

Incentivizing Health Care Providers

• How Advocate Health System Uses Behavioral Economics to Motivate Physicians in its Incentive Program. “Because P4P programs have not reliably been effective, this case study explores Advocate’s program and the key features that its leadership believes are responsible, in large part, for its success. We examine Advocate’s program in the context of its behavioral economic design principles that support physician engagement and performance.” (Healthcare, 5.25.16)
• Nudging Physicians Toward Value: Incentives In The Era of MACRA-Economics. Free webcast. “We need to redesign the offices, but we also need to redesign how people approach the care of individual patients, and for that we need to change their financial incentives as well as their non-financial incentives… We’ve tried some version of these things, mostly under the rubric of P4P, P4Q, whatever your favorite label is, and we know that’s been a miserable failure. It has not actually moved the needle substantially.” Emanuel, Ezekiel. (Commonwealth Fund, 6.2.16)
• Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care. “This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided.” Emanuel et al. (Annals of Internal Medicine, June, 2016).
• Changing Physician Behavior is Harder Than We Thought. “Two recently released unrelated reports serve as stark reminders of how challenging it has been to change physician behavior in a sustained and purposeful way. This isn’t to suggest we shouldn’t keep working to find strategies for delivering US health care more effectively and efficiently, but the reports’ findings underscore the importance of setting realistic expectations… In a case of ironic timing, the CMS announced the agency’s ‘largest-ever multi-payer initiative’ to change how primary care is delivered (http://1.usa.gov/1UZdgmL) just a few days before publication of the discouraging results from the Comprehensive Primary Care initiative’s midterm assessment (but obviously long after those results were known). This new effort, called Comprehensive Primary Care Plus (CPC+), plans to include as many as 5000 practices in 20 regions and will feature 2 ‘tracks,’ with different requirements and payment options… it is difficult to independently document much improvement. I’m not suggesting that finding out what doesn’t work isn’t critical to finding out what will work. I’m also not suggesting that there has been a lack of will or interest in tackling either of these areas. But it is hard to ignore that there is little evidence that we’ve made much measurable progress in addressing these problems.” Wilensky, Gail. (JAMA, 7.5.16)

Incentivizing Patients

• Patient Compliance – The Future Will Be Tougher. “Patient compliance – or adherence, or alliance – is likely to become even more important and more all-encompassing for doctors as healthcare reform proceeds. Compliance tactics that doctors may need could be more extensive than they are now, as physicians will be required to work harder to get patients to ‘get with the program.’  ‘A lot of what you now think is the patient’s fault will become your fault,’ says healthcare consultant James E. Orlikoff, president of Orlikoff & Associates, Chicago, and national advisor on Governance and Leadership to the American Hospital Association and Health Forum. ‘If the patient’s not going to do what you want, you’re going to be engaging with your patients in ways you never thought about.’… Still, it’s simply too glib and politically easy to load all responsibility onto the physician and let the patient off scot-free. It’s far more of a crowd-pleaser and vote-getter to make the physician shoulder the blame than to tell patients, ‘You have an obligation to be responsible for many or most aspects of your health.’”  (Medscape: The Kane Scrutiny, 10.15.10)

Pay-for-Performance in Medicare

Initiatives

Hospital Value-Based Purchasing Program (HVBP)
Changes to Medicare’s Physician Quality and Reporting System (PQRS)
Physician Compare Reporting
Value-Based Physician Payment Modifier (VBPM)
The Hospital-Acquired Condition (HAC) Reduction Program
Hospital Readmissions Reduction Program (HRRP)
Medicare Advantage Plan Bonus Payments
End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)
Comprehensive ESRD (End-Stage Renal Disease) Care (CEC) Model
Advanced Primary Care Initiatives
Comprehensive Primary Care (CPC)
Multi-payer Advanced Primary Care Practice (MAPCP)
FQHC Advanced Primary Care Practice Demonstration (FQHC APCP)
Million Hearts®: Cardiovascular Disease Risk Reduction Model (Million-Hearts-CVDRRM)
Bundled Payment Demonstrations
Episode Payment Models
Cardiac Rehabilitation Incentive Payment Model
The CMS Oncology Care Model (OCM)
Shared Decision Making (SDM) Model
Direct Decision Support (DDS) Model
Medicare Shared Savings Program (MSSP)

Medicare Access and CHIP Reauthorization Act (MACRA)

Outcomes in Medicare Pay-for-Performance Programs

Analysis of P4P in the General Health Sector

• What Obamacare’s Pay-For-Performance Programs Mean for Health Care Quality. “While Obamacare’s pay-for-performance programs for Medicare are either in the early stages of implementation or have already gone into effect, policymakers will continue to debate whether this approach can create the degree of quality improvement needed in the delivery of American health care. In addition to the major issues highlighted above, still others have been noted, including the complexity of the program structure, use of quality metrics that do not reflect aspects of care that matter to patients, and the simple fact that, though measures undergo rigorous review and alteration, they cannot take into account the real-world variability and dynamism of medical practice.” (The Heritage Foundation, 11.20.13)
• Grading a Physician’s Value — The Misapplication of Performance Measurement. “Although we agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future. Instead of helping to establish a central role for performance measurement in holding providers more accountable for the care they provide and in informing quality- and safety-improvement projects, this policy overreach could undermine the quest for higher-value health care… Even if we had better measures, behavioral economists would still challenge the pay-for-performance concept, at least for professionals such as physicians and teachers, who must manage complex situations and creatively solve problems. These critics argue that rewarding professionals on the basis of a particular performance measure has the potential to crowd out the intrinsic motivation to perform well across the board, not just on the few activities being measured.” (NEJM, 11.28.13)
• Who Is the Better Radiologist? Hint: It’s Not That Easy. “There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes. In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?… The trouble with quality is not just that it is nebulous in definition and protean in scope. It can mean whatever you want it to mean on a Friday. It is that it comprises elements that are inherently contradictory. Society, whatever that means these days, must decide what it values, what it values more and how much of what it values less is it willing to forfeit to attain what it values more. Before you start paying physicians for performance and docking them for quality can we be precise about what these terms mean, please?” Jha, Saurabh. (KevinMD, 8.9.14)
• How Medical Care Is Being Corrupted.  “Contracts for medical care that incorporate ‘pay for performance’ direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice… Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.” (New York Times, 11.18.14)
• Physicians Are Talking: Why Punish Docs for Patient Actions? “As payers begin to shift to outcomes-based reimbursements, physicians with high percentages of nonadherent patients stand to potentially see payments fall. Patients who don’t take their medications or don’t adhere to treatment recommendations are at risk of getting sicker and requiring more services, and this added cost could come out of physicians’ reimbursement. A recent Medscape article explored the fairness of this situation, where physicians are penalized for poor outcomes which they are usually helpless to control, but patients aren’t penalized for poor adherence or nonadherence, as if doctors were to blame.” Article publishes physician responses to the article. (Medscape Business of Medicine, 12.15.14)
• Designing Smarter Pay-for-Performance Programs. “Over the past decade, public and private payers have experimented with the use of financial incentives to motivate physicians to achieve quality and efficiency. The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.” (Journal of the American Medical Association, 12.24.14)

Pay-for-Performance at the Veterans’ Administration

• CAGW: VA Scandal Demands Scrutiny of Federal Pay-For-Performance Bonuses. “Today, Citizens Against Government Waste (CAGW) called for a total reevaluation of the federal employee bonus system after revelations that dozens of officials at multiple Veterans’ Administration (VA) medical facilities under investigation by the VA’s Office of Inspector General (OIG) received millions in bonuses while the facilities were under scrutiny. ‘The federal bonus system is an inscrutable, unaccountable black box,’ said CAGW President Tom Schatz. ‘The unfolding scandal at the VA is currently and correctly focused on the immediate plight of our wounded servicemen and women and allegations of data manipulation by VA officials. But reports that officials under investigation might have received cash bonuses while their activities were under investigation for these transgressions add insult to injury and, once again, calls into question the credibility of the entire federal bonus system.’” (Yahoo Finance, 5.23.14)
• Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says. “Meeting the performance objectives, which made executives eligible for bonuses and put them in line for promotions, became the overriding imperative among VA executives, according to both Spann and the whistleblower… The VA’s performance measures were originally established to provide uniform criteria for evaluating employees.  The idea was to use the grading system to reward those who met the standard with bonuses and identify those who were lagging behind. But over time, VA executives realized that the wait time numbers they reported were almost more important than anything else—including the actual care they provided veterans—in how they were judged by the VA’s leadership. At that point the measures became a perverse incentive, encouraging VA facilities across the country to hide problems by cheating their numbers. Eventually, cooking the books became an alarmingly regular procedure—a standard that might have remained if it hadn’t been exposed in Phoenix and unraveled over the past month… ‘If one person comes up with a way to cheat on a report to the government and profit from that lie, that’s defrauding the government,’ the whistleblower said. ‘If [hundreds] of people are defrauding the government, it’s a conspiracy, and that’s what you’ve got now and it runs coast to coast and bottom to top.’” (Daily Beast, 5.27.14)
• A Push for Better Ratings Puts Patients at Risk, Doctors Say. “In 2016, administrators began cherry-picking cases against the advice of doctors — turning away complicated patients and admitting only the lowest-risk ones in order to improve metrics, according to multiple interviews with doctors and nurses at the hospital and a review of documents. Those metrics helped determine both the Roseburg hospital’s rating and the leadership’s bonus checks. By denying veterans care, the ratings climbed rapidly from one star to two in 2016 and the director earned a bonus of $8,120. Current and former staff members say the practice may reach well beyond Roseburg. Recent government reports also challenge the reliability of the department’s metrics, casting doubt on a key tool that it says it relies on for reforming its beleaguered health care system.” (New York Times, 1.1.18)

Pay-for-Performance on the ACA Exchanges

The U.S. Department of Health and Human Services (HHS) issued its final notice in February, 2015, establishing benefit and payment parameters for 2016. To obtain qualified health plan (QHP) certification, issuers on the ACA exchanges must implement a quality improvement strategy (QIS)—a payment structure that provides increased reimbursement or other incentives to improve health outcomes, reduce hospital readmissions, improve patient safety and reduce medical errors, implement wellness and health promotion activities, and reduce health and health care disparities. The Rule supports Section 1311(g)(1) of the Affordable Care Act.
“We anticipate that the implementation plan for a QHP issuer’s proposed QIS would reflect a payment structure that provides increased reimbursement or other market-based incentives for addressing at least one of the topics in Section 1311(g)(1) of the Affordable Care Act.”

• Health Insurance Standards Under the Affordable Care Act. §156.1120 Quality Rating System. (a) Data submission requirement: (1) A QHP issuer must submit data to HHS and Exchanges to support the calculation of quality ratings for each QHP that has been offered in an Exchange for at least one year. (2) In order to ensure the integrity of the data required to calculate the QRS, a QHP issuer must submit data that has been validated in a form and manner specified by HHS. (3) A QHP issuer must include in its data submission information only for those QHP enrollees at the level specified by HHS. (b) Timeline. A QHP issuer must annually submit data necessary to calculate the QHP’s quality ratings to HHS and Exchanges, on a timeline and in a standardized form and manner specified by HHS. (c) Marketing requirement. A QHP issuer may reference the quality ratings for its QHPs in its marketing materials, in a manner specified by HHS. (d) Multi-State plans. Issuers of multi-State plans, as defined in §155.1000(a) of this subchapter, must provide the data described in paragraph (a) of this section to the U.S. Office of Personnel Management, in the time and manner specified by the U.S. Office of Personnel Management.” (Department of Health and Human Services, 5.27.14)
• Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016. The ACA requires exchange plans to maintain a “quality improvement strategy” designed to prevent hospital readmissions, improve health outcomes, reduce health disparities and meet other quality improvement goals. The Centers for Medicare and Medicaid Services (CMS) implement this requirement with a focus on quality improvement strategies that use value-based purchasing concepts. The rule emphasizes the importance of aligning insurers’ provider payment and quality improvement strategies with those efforts already underway in the Medicare program and other public and private sector payment reform initiatives. “We believe that aligning QHP issuer standards for quality improvement strategies in Exchanges with existing initiatives would reinforce national health care quality priorities while reducing the burden on health plans and stakeholders to implement different and multiple program requirements.” (Center for Medicare and Medicaid Services, 11.26.14)

Timeline

• CMS, November 2015: “An issuer applying for QHP certification in the FFMs for the 2017 coverage year is expected to submit a QIS Implementation Plan and Progress Report form during the 2016 QHP application submission window, and then implement the QIS beginning no later than January 2017.”
• “The standards requiring QHP issuers participating in Exchanges to establish and submit information regarding a quality improvement strategy will encourage continuous quality improvement among QHP issuers to help strengthen system-wide efforts to improve health outcomes at lower costs, promote provider payment models that link quality and value of services, allow for flexibility and innovation of diverse market-based incentive approaches, encourage meaningful improvements as well as provide regulators and stakeholders with information to use for monitoring and evaluation purposes.”

Analysis

• Value-Based Health Care Purchasing: Essential Health Benefits and State Health Insurance Exchanges. “Although reducing the number of people without health insurance will provide relief by curtailing much of the estimated $50 billion in annual cost-shifting onto the insured, the longer term challenges are more complex, because they involve structural change in how health care is organized, delivered, and paid for… This Implementation Brief focuses on how the Affordable Care Act (ACA) promotes value-based purchasing through state health insurance Exchanges.” (Health Reform GPS, 1.25.11)
• The Affordable Care Act’s Requirements for Quality Improvement in the Health Insurance Marketplaces: What Recent Federal Action Tells Us. “The ACA requires plans participating on the marketplaces to maintain a ‘quality improvement strategy’ designed to prevent hospital readmissions, improve health outcomes, reduce health disparities and meet other quality improvement goals…Beginning in the fall of 2016, insurers that participated in one or more marketplaces in 2014 and 2015 will have to submit a quality improvement plan to CMS, followed by annual progress updates. While CMS is not specifying precise elements for insurers’ quality improvement strategies, they indicate that they’ll be looking for strategies that link provider payments to the quality and value of their performance… The ACA and federal rules require insurers to collect and report data that will support the development of quality rating scores for each of their plans offered through the marketplace. In addition, they must contract with an approved vendor to conduct enrollee satisfaction surveys. The FFM will use this data to rate each participating plan through a 1- to 5-star rating scale.” (Center on Health Insurance Reform, 1.7.15)

Findings

Outcomes in Medicare Pay-for-Performance Programs

• Hospital Penalties
• Hospital Value-based Purchasing Program (HVBP)
• Bundled Payment Demonstrations
• Comprehensive Primary Care Initiative (CPC)
• Medicare Advantage Quality Bonus Payment Demonstration

P4P Impact on Quality of Care

• Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings. “Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non–English-speaking patients were associated with lower quality rankings for primary care physicians… Our findings provide evidence of the effect of patient panel makeup on attainment of HEDIS quality measures and support our hypothesis that patient panel characteristics are associated with changes in relative physician quality scores. Furthermore, our study demonstrates possible effects of this finding on misclassification of physicians when ranking or tiers are used to compare physician quality and reveals a potential mechanism for unintended consequences posed by physician clinical performance assessment in the setting of performance incentive programs.” (JAMA,  9.8.10)
• Quality Still Accounts for Minor Slice of Physician Pay. “Judging by survey data released last week by the Medical Group Management Association (MGMA), the paradigm hasn’t shifted very much. Group practices on average based roughly 6% of total compensation on quality measures for both primary care physicians (5.96%) and specialists (5.7%) in 2013. Some common examples of quality measures are the percentage of patients with hypertension who have their blood pressure under control, and the percentage of diabetic patients who receive an annual eye exam. Patient satisfaction scores amounted to another 1.9% of compensation for primary care physicians and 2.3% for specialists last year…But is making quality of care a 6% slice of the dollar pie enough to change how physicians practice? No, said Uwe Reinhardt, PhD, a professor of healthcare economics at Princeton University. To get physicians’ attention, he said, the quality slice needs to be at least 20%.” (Medscape Medical News, 7.10.14)
• Effect of Pay-for-Performance Incentives on Cancer Screening. “There is limited evidence for the effectiveness of pay-for-performance despite its widespread use. We assessed whether the introduction of a pay-for-performance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program. We found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. The pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening.” Kiran, T., Wilton, A.S., Moineddin, Paszat, L., Glazier, R.H. (Annnals of Family Medicine. 2014;12(4):317-323)

P4P Impact on Patient Satisfaction

• Some of the Country’s Best Doctors Have the Worst Patient Satisfaction Scores. Here’s Why. “Armed with the idea that ‘patient is always right,’ Washington figured that more customer satisfaction data ‘will improve quality of care and reduce costs.’ That turns out to have been a bad bet. In fact, the most satisfied patients are 12 percent more likely to be hospitalized and 26 percent more likely to die, according to researchers at UC Davis. ‘Overtreatment is a silent killer,’ wrote Dr. William Sonnenberg in his recent Medscape article, Patient Satisfaction is Overrated. ‘We can over-treat and over-prescribe. The patients will be happy, give us good ratings, yet be worse off.’” (The Daily Beast, 5.21.14)
• Physician Believes Obamacare’s Emphasis on Pay-for-Performance Will Hurt Minorities.  [OPINION]: “How Obamacare Will Screw Black Physicians. Although I have been an Obama supporter, it’d be disingenuous if I didn’t conclude that we’re faced with the fascinating paradox that the signature policy of the first black president may indeed serve to increase our racial divides.” (The Daily Beast, 5.26.14)
• Patient Satisfaction and Quality of Care: Are They Linked?: Reigning in the Business Model. Interview with Joshua J. Fenton, MD, MPH: “‘I can envision a blended payment scheme that simultaneously rewards volume, technical quality, and patient experience. But we need to be wise about the perverse incentives that each measure may introduce. If the payment scheme overemphasizes patient satisfaction, particularly maximal satisfaction, then financial incentives may steer some physicians from the hard work of addressing difficult topics with patients, and may lead to more low-value tests or treatments, and physician attempts to avoid difficult-to-satisfy but vulnerable and needy subgroups of patients.’” (Medscape Family Medicine, 6.11.14)
• Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality. “The Centers for Medicare and Medicaid Services include patient experience as a core component of its Value-Based Purchasing program, which ties financial incentives to hospital performance on a range of quality measures…Of the 180 hospitals, the overall mean patient satisfaction score was 68.0% (first quartile mean, 58.7%; fourth quartile mean, 76.7%). Compared with patients treated at hospitals in the lowest quartile, those at the highest quartile had significantly lower risk-adjusted odds of death (odds ratio = 0.85; 95% CI, 0.73-0.99), failure to rescue (odds ratio = 0.82; 95% CI, 0.70-0.96), and minor complication (odds ratio = 0.87; 95% CI, 0.75-0.99). This translated to relative risk reductions of 11.1% (P = .04), 12.6% (P = .02), and 11.5% (P = .04), respectively. No significant relationship was noted between patient satisfaction and either major complication or hospital readmission.” (JAMA Surgery, 6.24.15)
• ObamaCare Is Fueling America’s Opioid Epidemic. “Time senior writer Sean Gregory says that ObamaCare’s patient satisfaction surveys are contributing to the growing problem of opioid abuse in the U.S. More than 60% of drug overdoses in 2014 were from a prescription opioid, and ERS treat more than 1,000 patients a day for misusing the drugs. What’s the connection? The satisfaction survey asks questions about things like hospital cleanliness, noise levels and staff communication. But it also asks questions about pain management, including whether the hospital did ‘everything they could to help you with your pain.’ Under ObamaCare, these patient satisfaction surveys, along with other quality measures, are tied to $1.5 billion in Medicare payments to hospitals, giving the hospitals a huge incentive to make sure they score well. The problem, Gregory notes, comes from ‘tying a patient’s feelings about pain management to a hospital’s bottom line,’ which ‘to many physicians and lawmakers struggling to contain the nation’s opioid crisis… is deeply ­misguided, if not downright dangerous.’” (Investor’s Business Daily, 4.14.16)
• The Patient Experience and Patient Satisfaction:Measurement of a Complex Dynamic. The concept of patient experience is surprisingly complex and generally linked with patient satisfaction. As reimbursement and performance policies have become more normative within healthcare, the patient experience has become a metric to measure payment systems for quality. However, we still have much to learn about the concept of patient experience and its influence on how patients report satisfaction with their care. (Online Journal of Issues in Nursing, 2016;21(1))

Analysis: Mixed Effectiveness of P4P Health Programs

• The Effect Of Pay-For-Performance In Hospitals: Lessons For Quality Improvement. “Over the first three years of the pay-for-performance demonstration project, participating hospitals had better average overall performance across all three medical conditions than hospitals that did not participate (Exhibit 1). However, the difference in average performance between the two groups started to diminish in 2007. By 2008 there was no statistically significant difference between the two groups, meaning that the effect of pay-for-performance was no longer detectable.” (Health Affairs, April, 2011).
• The Long-Term Effect of Premier Pay for Performance on Patient Outcomes. “In the Affordable Care Act, the U.S. Congress mandated the CMS to adopt a pay-for-performance program for hospitals nationwide. CMS responded by creating the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance — an approach closely modeled after the Premier HQID during the latter part of the study period. Currently, VBP focuses on incentives for process measures (along with metrics of the patient’s experience), but in 2013, it will be broadened to include 30-day mortality… we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.” (New England Journal of Medicine, 3.28.12)
• Will Pay For Performance Backfire? Insights From Behavioral Economics. “While Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.” (HealthAffairs, 10.11.12)
• Health Policy Brief: Pay-for-Performance. “This policy brief reviews the background and current state of public and private pay-for-performance initiatives. In theory, paying providers for achieving better outcomes for patients should improve those outcomes, but in actuality, studies of these programs have yielded mixed results. This brief also discusses proposals for making these programs more effective in the future.” (Health Affairs, 10.11.12)
• What Obamacare’s Pay-For-Performance Programs Mean for Health Care Quality. “While Obamacare’s pay-for-performance programs for Medicare are either in the early stages of implementation or have already gone into effect, policymakers will continue to debate whether this approach can create the degree of quality improvement needed in the delivery of American health care. In addition to the major issues highlighted above, still others have been noted, including the complexity of the program structure, use of quality metrics that do not reflect aspects of care that matter to patients, and the simple fact that, though measures undergo rigorous review and alteration, they cannot take into account the real-world variability and dynamism of medical practice.” (The Heritage Foundation, 11.20.13)
• Promise of Value-Based Purchasing in Health Care Remains to Be Demonstrated. “After a decade of experimentation with reforms that give health providers financial incentives to improve performance, relatively little is known about how to best execute such strategies or judge their success, according to a new RAND Corporation report. A comprehensive report designed to assess the state of knowledge about value-based purchasing programs in health care found that evidence thus far is mixed about whether using such payment schemes can help improve quality and lower costs. Most of the research on value-based purchasing has examined the effects of pay-for-performance programs that reward physicians and other health providers for improving the quality of care or reducing costs. Research is needed to understand the impacts of newer value-based payment models, such as accountable care organizations (ACOs) and bundled payments, that create stronger financial incentives for change, according to the report… Studies done to date on value-based purchasing have been inconclusive, with some showing modest cost savings and quality improvements, and others finding no meaningful changes. In addition, many of the studies about value-based purchasing had design flaws that make it hard to determine whether the intervention had an effect beyond other changes that were occurring in health care to cut costs and improve quality.” (RAND Corporation, 3.4.14)
• Obamacare’s Payment Pilots Are Struggling To Prove They Work. Here’s Why It’s OK. “It’s worth the risk, experts say. Although with several years of experience, they’re adopting an ever-savvier way of thinking about payment reforms now. After Catalyst for Payment Reform was founded in 2010, Delbanco says, leaders set a goal for the industry: to get 20% of provider payments based on value by 2020. More than three years later, that goal hasn’t changed — but there’s been a telling shift in how she talks about it. ‘We still want 20% of payments to doctors and hospitals [to] flow through methods of payment that are proven to improve the value,’ Delbanco now says. ‘Because it would be terrible if we woke up in six years to realize that 85% of payments are flowing through value-oriented methods,’ she adds, ‘and they’re not producing the results we hoped they would.’” (The Healthcare Blog, 3.5.14)
• The Payment Reform Landscape: Pay-For-Performance. “Historically the evidence has been mixed as to whether pay-for-performance models improve quality and affordability. Throughout the U.S., there are several examples of pay-for-performance models; many of these were examined in a Health Affairs/Robert Wood Johnson Foundation Health Policy Brief on the topic in 2012. That brief concluded, ‘Despite limited evidence of effectiveness, pay-for-performance remains popular among policy makers and public and private insurers as a tool for improving quality of care and containing health care costs.’… One Catalyst for Payment Reform hypothesis is that payment methods may be most powerful when there is some potential downside financial risk for providers. If this hypothesis holds true, pay-for-performance models will have better results when they morph into shared-risk arrangements.” (Health Affairs, 3.14.14)
• Obamacare Needs to Change the Way Doctors are Paid to Achieve Real Reform. Compares Pay-for-Performance with other reimbursement models. “‘Pay for performance’ provides incentives for preventive care.  However, evidence suggests preventive care might have little effect on health outcomes and expenditures.” (Philly.com, 4.21.14)
• Health Law’s Pay for Performance Policy Is Skewed, Panel Finds. “Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.” (New York Times, 4.28.14)
• Good News And Bad News About Value Based Healthcare. “The good news is that research done by CPR in conjunction with the National Business Coalition on Health finds that adoption of value-oriented payment is indeed on the rise nationally. Forty cents of every healthcare dollar is now tied in some way to value—up from only eleven cents a year ago. Unfortunately, there’s also some bad news: we’re not sure it’s making a difference yet. ‘Value-oriented payment only succeeds if we improve quality and safety,’ said Andréa Caballero, CPR’s study leader. Indeed, my nonprofit, the Leapfrog Group, monitors hospital quality and safety and has not found dramatic change consonant with the shifts in value-oriented payment now being reported. ‘It’s time to measure the value of value,’ said one of CPR’s (and Leapfrog’s) founders, Equity Healthcare CEO Dr. Bob Galvin, MD., during the event. Binder, Leah. (Forbes, 10.1.14)
• Tweaks Still Needed in P4P Programs. “Pay-for-performance (P4P) incentives may eventually work for providers, but they will require more fine-tuning, several experts said at a briefing sponsored… Did the efforts work as intended? ‘If [they] had, we wouldn’t be here,’ Jha said. ‘Mostly it didn’t work very well.’ There are some ways to possibly make P4P a little more successful, he noted.” (MedPage Today, 10.18.14)
• Bad News For Obamacare: Pay-For-Performance Doesn’t Work. “One of the central promises of Obamacare was to control cost and improve quality by changing the way we pay for health care. In all its guises that essentially means paying doctors and institutions more if they produce better results. Here’s the problem: it doesn’t work. Aaron Carroll reports on the latest failed experiment and notes that this is only one of a long line of disappointments with bleak prospects for any future efforts. In a previous post he writes: ‘I’m getting to be a broken record in my skepticism about pay for performance. Here, here, here, here, here, and here just to name a few posts.’ Why aren’t the pilot programs and demonstrations projects working? The biggest stumbling block is the whole concept of ‘quality.’” Goodman, John C. (Forbes, 10.20.14)
• Are Hospital Pay-for-Performance Programs Failing? “A recent review of literature on pay-for-performance by professor of population medicine Stephen Soumerai argues that many studies showing promising results for pay-for-performance in the United Kingdom have methodologies so flawed as to be useless… Findings like these, Soumerai warned, can wrongly encourage other nations to commit billions of dollars to pay-for-performance programs. He suggests that expensive policies should always be supported by evidence from controlled, experimental or quasi-experimental studies, like randomized control trials, where patients are randomly assigned to different intervention groups (in this case, to either a pay-for-performance or non-pay-for-performance hospital), and their results then compared. Systematic reviews consistently show no gains from pay-for-performance. Why then does it continue to make its way into policy, in the United States and elsewhere? Soumerai, who has been publicly critical of financial incentives in healthcare, challenges the basic assumptions that go into economic models. ‘Health economists invent these things in their offices and advise presidents and Congresses, but they don’t talk to doctors in the field about what’s important to them, or how you might improve practice,’ he said. ‘It’s much easier to say, We’ll pay for an outcome or penalize against it.’  Policymakers need to become much better at understanding the conditions in which doctors work that aren’t captured by theory, he argued.” (Harvard Magazine, 6.29.16)
• Why Health Care’s Flawed ‘Pay for Performance’ Model Needs Rethinking. “Two leading health policy experts zeroed in on problems with Medicare’s ‘pay for performance’ model in a Center for Health Journalism webinar Tuesday, arguing the current incentive-based reimbursement system isn’t significantly improving care or curbing spending. Despite Obamacare’s emphasis on using payments to incentivize better care, pay for performance ‘is an idea whose time has passed,’ said Dr. Robert Berenson, a fellow at the Urban Institute who focuses on health care delivery. Even so, since you ‘can’t put genie back into the bottle,’ Berenson urged a smarter approach to the government’s payment system… Even though the strategy has gained popularity — the Obama administration has called for half of all Medicare payments to be performance based by 2018 — the evidence hasn’t been encouraging. Instead, the movement has led providers to ‘game the system’ and penalized safety-net hospitals, which serve the poorest patients, panelists said… Since the pay-for-performance model is here to stay, Jha suggested it’s time to reframe the debate from ‘Does pay for performance work?’ to ‘How do we get pay for performance to work?’… he pointed out the high administrative costs involved in pay for service models, such as the $15.4 billion annually for physician practices to report quality measures. ‘That’s $15 billion that could be spent improving people’s health care,’ he said.” (Annenberg Center for Health Journalism, 6.30.16)
• The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review. “Among 69 studies, 58 were in ambulatory settings, 52 reported process-of-care outcomes, and 38 reported patient outcomes. Low-strength evidence suggested that P4P programs in ambulatory settings may improve process-of-care outcomes over the short term (2 to 3 years), whereas data on longer-term effects were limited… The largest improvements were seen in areas where baseline performance was poor. There was no consistent effect of P4P on intermediate health outcomes (low-strength evidence) and insufficient evidence to characterize any effect on patient health outcomes. In the hospital setting, there was low-strength evidence that P4P had little or no effect on patient health outcomes and a positive effect on reducing hospital readmissions… Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.” (Annals of Internal Medicine, 3.7.17)
• Pay for Performance Lacks Evidence of Clear Benefit. “Teryl K. Nuckols, MD, MSHS, from the Division of General Internal Medicine at Cedars-Sinai Medical Center in Los Angeles, California, says lack of evidence that P4P is making a significant difference is particularly important because it is now national public policy with the advent of the Merit-Based Incentive Payment System (MIPS). He also notes the lack of consistent findings: ‘Most of the studies had major methodological limitations, such as lack of a control group, and the more rigorous studies reported less favorable findings.’ He says uncertainty about incentives will continue with the switch to MIPS. For one thing, MIPS is a system of both penalties and rewards, while previous studies have focused on rewards. Penalties “tend to have stronger effects on human behavior,” Dr Nuckols notes. Also, MIPS is a complex system and awards incentives 2 years after care is provided, he says, noting that ‘[s]imple choices and immediate feedback are generally more influential than complex choices and delayed feedback.’… It also remains to be seen whether physicians will game the system.” (Medscape Medical News, 1.10.17)
• Is the Future of Value-Based Payment at Risk? “The transformation we are talking about, of course, is the shift to value-based payment. What is in doubt, however, is whether this transformation can continue at its current pace. The future of value-based payment may be at risk unless industry comes together quickly to decide how information needed to support this model should be identified, sourced, accessed and shared.” (Modern Healthcare, 2018)

Insurer-led P4P Programs

• Michigan’s Fee-For-Value Physician Incentive Program Reduces Spending And Improves Quality In Primary Care. “We examined Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program, which uses a fee-for-value approach focused on primary care physicians. We analyzed the program’s impact on quality and spending from 2008 to 2011 for over three million beneficiaries in over 11,000 physician practices. Participation in the incentive program was associated with approximately 1.1 percent lower total spending for adults (5.1 percent lower for children) and the same or improved performance on eleven of fourteen quality measures over time. Our findings contribute to the growing body of evidence about the potential effectiveness of models that align payment with cost and quality performance, and they demonstrate that it is possible to transform reimbursement within a fee-for-service framework to encourage and incentivize physicians to provide high-quality care, while also reducing costs.” (Health Affairs, April, 2015)
• Anthem Touts Results of Effort to Cut Health Costs. “Anthem Inc. said a major effort to overhaul how it pays primary-care doctors appears to be lowering overall health-care costs, as patients spend less time in the hospital… Independent researchers who reviewed a summary of the study’s methodology said the design was generally strong, but the findings so far represent an early look and haven’t been peer-reviewed. ‘You have to interpret with caution,’ said J. Michael McWilliams, an associate professor at Harvard Medical School, who said the study results might to some degree reflect trends that were under way earlier.” (Wall Street Journal, 4.28.15)

ACA’s P4P Reform of the Health Sector

• Open Letter to President Obama About His JAMA Paper. “The ACA could become what Henry Aaron predicted in 2010 it might become – ‘zombie legislation, a program that lives on but works badly.’ Just because you’re leaving office doesn’t mean you must sit on the sidelines and watch the ACA take a slow nose dive. If you set aside some time after you leave office to immerse yourself in health policy, and if you give high priority to finding the truth and low priority to making the ACA look good, you will conclude as I have that the ACA has little cost containment in it. You’ll conclude, as I have, that Peter Orszag, Zeke Emanuel, Jeanne Lambrew and the other advisors who told you ‘accountable care organizations’ and other pay-for-performance fads could cut costs were merely regurgitating groupthink developed over the last half-century by the managed care movement. And once you have determined that ACOs and the other cost-containment nostrums in the ACA are not lowering inflation and some (notably ACOs and ‘medical homes’) may actually be inflationary, you can then use your influence to educate Congress and the health policy elite about why the ACA is aggravating inflation and what should be done about it.” Sullivan, Kip. (The Health Care Blog, 8.24.16)
• Underuse is Rampant, But Overuse is All We Talk About. “I devote this comment to a review of some of the evidence that indicates underuse (the failure of the health care system to deliver necessary care) is more prevalent than overuse. Knowing that fact is useful not just for understanding my criticism of Obama but for understanding how flimsy the justification is for accountable care organizations and other managed care nostrums. I have only enough space here to introduce you to the best of the under- and overuse literature. I believe it will be enough to convince you that underuse is more common than overuse. Once you comprehend that fact, you’ll also comprehend that it is neither logical or ethical to base health policy on the assumption that overuse is the only form of inappropriate use we must address. If we view underuse as an equally serious problem, then it makes no sense to promulgate managed care notions (such as shifting insurance risk to doctors) designed to address overuse.” Sullivan, Kip. (The Health Care Blog, 10.6.16)
• Peter Orszag’s Obsession with Overuse. “One of the great unexplained mysteries in the history of the Affordable Care Act is how Orszag ignored research he supervised that debunked the thesis Orszag sold to Obama. The research I’m talking about is a massive CBO report released in December 2008 entitled Budget Options, Volume 1, Health Care which threw cold water on numerous unproven managed care fads, including ACOs, medical homes, comparative effectiveness research, and penalizing hospitals for ‘excess admissions.’ The Budget Options report, which examined 115 health care reform ‘options,’ said the managed care fads would at best save the federal government microscopic sums of money over the decade 2010-2019 compared to the trillions of dollars Medicare and Medicaid would spend over that decade (and that wasn’t counting the costs to insurers and providers of implementing those proposals)… Orszag’s overnight conversion to the Dartmouth ideology epitomizes what has been so wrong with the managed care culture since the early 1970s: Smart people surrender their critical faculties to health policy entrepreneurs bearing quarter-truth diagnoses and cleverly packaged, evidence-free solutions (HMOs, ACOS, pay-for-performance). They become true believers. Evidence that contradicts the ideology is ignored.” Sullivan, Kip. (The Health Care Blog, 10.12.16)

Health Care Quality Measurement

Overview

Pay-for-performance relies upon accurate measurement of health care service quality. A number of quality measures have been applied to health care institutions and providers over the years as a result of the Affordable Care Act, many of which do not correspond with other systems’ measures. An effort began in 2015-2016 to align these markers with others.

The Burden

• Quality Measurement is Getting Out of Hand, MedPAC Says. “Providers are being overly burdened by increasing numbers of quality measures, the Medicare Payment Advisory Commission stated in a recent letter to a top health official. The government should take a step back and reevaluate its approach, the letter added. The missive came in response to an annual list of quality measures that are under consideration, issued in December by the Centers for Medicare & Medicaid Services. This year’s list ran to 329 pages and included hundreds of measures that might be adopted to ascertain the quality of care furnished by Medicare-certified providers.” (McKnights, 1.15.15)
• How Measurement Fails Doctors and Teachers. “All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100,’ ‘honor roll,’ grade ‘A’ or ‘best’ hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures… ‘The secret of quality is love,’ he said. Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.”  (New York Times, 1.16.16)
• Physicians Bleeding Money to Report Quality Metrics. “Fifty years ago, Avedis Donabedian, MD, MPH, of the University of Michigan, published his seminal paper, ‘Evaluating the Quality of Medical Care,’ and created a framework that is still used to measure healthcare quality. Donabedian divided quality measures into three categories: structure, processes and outcomes. Efforts are now underway to expand his paradigm into a potent, data-driven network of quality measures, with the hope of streamlining and vastly improving America’s healthcare system. In the short term, this initiative has turned into an expensive, burdensome, data-wrestling nightmare for many medical practices, says Lawrence P. Casalino, MD, PhD, MPH, a family physician who is a professor in the Department of Health Policy at Weill Cornell Medicine in New York, New York. Casalino and associates published an article in the March edition of Health Affairs entitled, ‘U.S. Physician Practices Spend More Than $15.4 Billion Annually to Report Quality Measures.’… That adds up to about $40,000 a year per physician, or $15.4 billion nationally, just for quality measures, according to the study.” (Medical Economics, 4.13.16)
• Measure Madness. “If the proliferation of required reporting of quality measures continues, “providers will need to invest so much money to report externally imposed measures that there will be scant funds left to support provider-specific internal measurement systems needed for monitoring and improving quality… Healthcare providers are simply exhausted from the burden of trying to respond to the volume of mandatory and voluntary requests for quality data, particularly with regard to measures that do not contribute to care improvement in their organizations. Moreover, this work consumes resources and attention that otherwise would be directed to patient care and addressing more meaningful quality priorities.”  (Healthcare Association of New York State, 2016)

• Lack of Patient Data, Quality Measures Slowing Shift to Value-based Care. “According to the survey, 74% of doctors and health plans executives said quality measures are too complex, making them hard for physicians to achieve, while 65% of physicians said they lacked important information about their patients. In addition, 64% of providers and payers said doctors don’t have the necessary tools to succeed in a value-based care model. And 85% of doctors said they would likely or very likely use a tool that provides real-time, on-demand patient-specific data to identify gaps in quality, risk and utilization. While the majority of respondents agreed that quality measures help to improve patient care, just over half — 54% — said physicians know which quality measures apply to individual patients under relevant value-based care models. When it came to perceptions of value-based care, 57% of payers said the U.S. healthcare systems should be value-based, rather than fee-for-service, versus 33% of physicians.” (Healthcare Dive, 6.15.16)
• NQF Coalition Calls for Removing Ineffective Quality Measures. “The National Quality Forum’s Measure Applications Partnership has taken the unusual step of suggesting the federal government consider culling approximately one-fifth of the metrics it uses to determine payment in seven federal healthcare programs. The recommendation came as part of its 2017 guidance to HHS, released Thursday. It suggested HHS think about removing 51 of 240 measures currently used to determine payment in those programs, to help streamline requirements for providers and make healthcare measurement more efficient… Federal healthcare programs currently contain 634 quality measures, and the healthcare industry has long contended that the reporting and data collection requirements for these measures impose too much of a burden on providers. At the same time, the industry is grappling with how best to pay for healthcare on the basis of value, not volume, a system that requires the sector to accurately measure the quality of care. This year, the measures MAP recommended removing included four out of 18 measures used in the End-Stage Renal Disease Quality Incentive Program, 13 out of 29 used in the Outpatient Quality Reporting Program and six out of 62 used in the Inpatient Quality Reporting Program. It also recommended removing measures from the Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program, the Ambulatory Surgery Center Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program and the Home Health Quality Reporting Program… These recommendations were different from MAP’s final recommendations, released in February, regarding 74 new measures that the federal government is considering using. Those recommendations ultimately supported 33 measures but asked the CMS to refine or stop work entirely on the other 41.” (Modern Healthcare, 3.16.17)
• Quality of Care: In Depth. “Although the field of quality measurement has blossomed over the past 20 years, current measures often fail to capture patient perspectives or outcomes explicitly. Flawed measures can have unintended consequences, and what isn’t measured can’t be monitored. Comprehensive sets of quality measures, including those developed by RAND such as the RAND Quality Assessment Tools and CAHPS® (Consumer Assessment of Healthcare Providers and Systems) have been called ‘transformative.‘ But more can be done, especially to develop performance measures that help providers and health systems achieve desirable outcomes (e.g., improved functioning) while also providing patient-centered care.” (RAND Corporation.)

Institute of Medicine Effort

• Measuring Vital Signs: An IOM Report on Core Metrics for Health and Health Care Progress. “The budding enthusiasm for performance measurement, however, has begun to create serious problems for public health and for health care. Not only are many measures imperfect, but they are proliferating at an astonishing rate, increasing the burden and blurring the ability to focus on issues most important to better health and health care. Measures of the same phenomenon also vary in specification and application, leading to confusion and inefficiency that make health care more expensive and undermine the very purpose of measurement, namely, to facilitate improvement. Not uncommonly, a health care organization delivering primary care to a typical population is asked to report and collect hundreds of measures aimed at dozens of conditions. In response to these issues, a new report from the Institute of Medicine (IOM), Vital Signs: Core Metrics for Health and Health Care Progress, addresses the major opportunities and current problems in the health care measurement enterprise. The document identifies a set of standardized measures required at national, state, local, and institutional levels.” (JAMA, 4.28.15)
• Vital Signs: Core Metrics for Health and Health Care Progress. “The necessity to collect, analyze, and store data for such a large number of measures also imposes a significant burden on providers, organizations, and the health care system as a whole. Preliminary research commissioned by the committee finds that the growth in measurement and reporting activities results in considerable expense and requires substantial time commitments—without a matching return on investment. The establishment of a core set of measures could improve efficiency and ensure a focus on the most important health outcomes.” (Institute of Medicine, April, 2015) The IOM recommends (April, 2015) the following measures:
  Life expectancy: Infant mortality; Maternal mortality; Violence and injury mortality
  Well-being: Multiple chronic conditions; Depression
  Overweight and obesity: Activity levels; Healthy eating patterns
  Addictive behavior: Tobacco use; Drug dependence/illicit use; Alcohol dependence/ misuse
  Unintended pregnancy: Contraceptive use
  Healthy communities: Childhood poverty rate; Childhood asthma; Air quality index; Drinking water quality index
  Preventive services:  Influenza immunization; Colorectal cancer screening; Breast cancer screening
  Care access:  Usual source of care; Delay of needed care
  Patient safety:  Wrong-site surgery; Pressure ulcers; Medication reconciliation
  Evidence-based care:  Cardiovascular risk reduction; Hypertension control Diabetes control composite; Heart attack therapy protocol; Stroke therapy protocol; Unnecessary care composite
  Care match with patient goals: Patient experience; Shared decision making; End-of-life/advanced care planning
  Personal spending burden: Health care–related bankruptcies
  Population spending burden: Total cost of care; Health care spending growth
  Individual engagement:  Involvement in health initiatives
  Community engagement: Availability of healthy food; Walkability; Community health benefit agenda

Core Quality Measures Collaborative

The Centers for Medicare & Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP) released seven sets of clinical quality measures in February, 2016. As reported by CMIO, physicians and other clinicians must currently report multiple quality measures to different entities and measurement requirements often are not aligned among payers, which has resulted in confusion and complexity for reporting providers. The Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. According to CMS, “this work is informing CMS’ implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) through its measure development plan and required rulemaking, and is part of CMS’ commitment to ensuring programs work for providers while keeping the focus on improved quality of care for patients.” Implementation of the measures will occur in several stages. “These seven core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based.” (CMIO, 2.16.16)

• ACO and PCMH / Primary Care Measures [PDF, 301KB]
• Cardiovascular Measures [PDF, 330KB]
• Gastroenterology Measures [PDF, 169KB]
• HIV / Hep C Core Measures [PDF, 155KB]
• Medical Oncology Measures [PDF, 179KB]
• OB/GYN Measures [PDF, 167KB]
• Orthopedic Measures [PDF, 162KB]

Quality Measurement Resources

• Measures That Matter. “Our new report, Measures that Matter, details the chaotic state of healthcare reporting and measurement, provides a clear call to action, and vision for the future of quality measurement where stakeholders use a common set of valid, reliable, and evidence-based measures to improve outcomes across the continuum of care. This comprehensive report also offers multiple measure management strategies and tools for healthcare providers.” (Healthcare Association of New York State, 2016)
• Value-Driven Health Care Primer. “The anticipation and anxiety surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is generating much conversation on the emergence of a healthcare payment system based on the quantification of value instead of a fee-for-service model. The accurate measurement of healthcare outcomes is made achievable through the application of validatable measurement instruments. The publication of ‘Value Driven Healthcare’ is meant to promote dialogue regarding the emergence of healthcare performance measurement and to provide an accessible way to begin those conversations. MACRA’s Merit-Based Incentive Payment System (MIPS) uses a combination of measurement instruments to compute Medicare reimbursements under the new rule. Download ‘Value Driven Healthcare’ by clicking on the image.” (OBERD, 8.23.16)
• Quality of Care: In Depth. “Although the field of quality measurement has blossomed over the past 20 years, current measures often fail to capture patient perspectives or outcomes explicitly. Flawed measures can have unintended consequences, and what isn’t measured can’t be monitored. Comprehensive sets of quality measures, including those developed by RAND such as the RAND Quality Assessment Tools and CAHPS® (Consumer Assessment of Healthcare Providers and Systems) have been called ‘transformative.‘ But more can be done, especially to develop performance measures that help providers and health systems achieve desirable outcomes (e.g., improved functioning) while also providing patient-centered care.” (RAND Corporation.)

P4P Resources

• Pay For Performance Research Clearinghouse
  
• Health Affairs April 2011; Volume 30, Issue 4. Still Crossing The Quality Chasm.
• Are Peformance-Based Accountability Systems Effective? Evidence from Five Sectors. (RAND Corporation, 2010)
• Evaluating the Quality of Medical Care. Donabedian, A. (11.9.05) DOI: 10.1111/j.1468-0009.2005.00397.x 
• All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments. CAQH CORE, 2018. “Value-based payment innovation and experimentation are ongoing, and numerous challenges may slow or prevent its ultimate progress. As this report demonstrates, without an efficient, uniform operational system, it will be difficult for stakeholders to achieve the fluid, reliable and trusted interactions and exchanges of data needed for long-term value-based payment success.”