Pay-For-Performance

In the November 2, 2006 issue of the New England Journal of Medicine (pp. 1845-1847) Elliott S. Fisher of Dartmouth provides a brief overview of pay-for-performance. He mentions the IOM study (also linked on this blog) as well as the AQA Quality set. The general concerns are summarized:

• Feasibility of implementation - most still emphasize provider-focused episodes and hence may make "fragmented care by multiple providers appear 'efficient'."
• Sufficiency of rewards - the arguments of collection cost vs. benefit and winners / losers as seen from the provider perspective
• Unintended consequences - includes mention that physicians may select heatlhier patients and refuse care to others; impact on the chronically ill

He argues for:

Implementation of P4P "as a means to learn hot to modify the payment system to foster higher performance and encourage systemwide and comprehensive improvement."

Targeting multiple dimensions of care including technical quality, patient-centered care and efficiency but "kmoving toward longitudinal and health-outcome measures as soon as it is feasible."

Systems that encourage "measures and rewards tha foster shared accountability and coordination of care."

Allowing Medicare beneficiaries to identify a primary care provider and then rewarding such providers

Voluntary participation by small-practice providers because of the serious data-collection challenges

Creation of modest funding pools derived from currentpayments to improve adoption by providers

A stronger evidential base for pay-for-performance in the "context of an effective monitoring and evaluation system that assesses early experiences...evaluates the approach's impact broadly...and identifies and disseminates informaiton on how to best improver performance.

Citing the weakness or current efforts, Fisher argues that "little attention is being devoted to designing or building a comprehensive evalution framework that would allow us to learn from our inevitable mistakes."