home email us! sindicaci;ón

The Rebranding of P4P

by JMoore

Last year I attended the Healthcare Quality and P4P (Pay for Performance) conference put on by the World Health Congress. This was my first healthcare conference and it provided me a great opportunity to gain a better understanding of the healthcare market and critical issues therein.

Well, its been a year now and once again I had the opportunity to attend this event. Unlike last year, I knew a lot more about the industry and market trends, thus did not get as much out of the event. But having been to more conferences than I could ever count one thing I have learned is that conferences are much like panning for gold - you have to sort through a lot of fool’s gold before you come across a nugget of the good stuff.

Following are gold nuggets I walk away with from this event.

P4P is out, gainsharing is in

Presenters, particularly payers discussed how they were using gainsharing (share the savings across all stakeholders contributing to quality improvements). A presentation by Howard Beckman of the Univ of Rochester was particularly insightful as he outlined three key terms of quality (underuse, overuse, and misuse) that were used when conversing, in a non-judgmental fashion, with physicians. By using these terms, backed with metrics from internal studies, they were able to gain much quicker buy-in among physicians into their quality improvement initiatives.

Another “hot” term was Value-based measurements - this may become the new P4P mantra for the coming year.

Future will see multiple forms of tiering

All payers are looking much more closely at stratifying populations for risks and becoming much more like disease and care management companies than just straight ahead insurers. This has been occurring for some time but the change here will be bringing in quality metrics to the equation and stratifying providers and payment schemes as well. During the medical home session, John Tooker of the American College of Physicians talked about a future where payment will be divided into three distinct categories (tiers): payment for procedure/service, another for care coordination and the third for meeting quality metrics/objectives.

There will be losers

Spoke to Dana Gleb Safran of BCBS-MA about the P4P initiative at BIDMC and asked what about radiology at BIDMC that saw a drop in business as a result of that program - will there be any gainsharing with them. She replied simply: No, we will not pay for unnecessary services, period.

Clearly there will be winners and losers as quality initiatives permeate the healthcare sector, but with numerous powerful and entrenched interests therein, even payers will struggle to get complete buy-in. One of the big problems they will face is defining what quality metrics to use, how to balance these measurements against such mitigating factors as population served and more broadly, coordination across multiple entities (local, state and federal government, internal operating procedures, employer-driven initiatives, specialists’ guidelines, etc.). It’s still a rat’s nest and it may take a while to untangle.

CMS moves at a snail’s pace

CMS presented their plans for a trial quality initiative to manage chronic care cases in a number of communities across the country. Plan is to provide an additional monthly payment to physicians providing care management with ongoing evaluation across a number of categories (e.g., value add, quality improvement, patient satisfaction, physician satisfaction, savings, etc. All good but it won’t be until sometime in 2010 that they actually begin the demonstration. That seems like an awfully longtime for just a demo. Are we in academia?

Another odd thing about that CMS demo is the requirement that the physician use IT to manage the care but there was no definition as to what that technology may be. Completely open-ended which makes me wonder how valid their results will be at the end of this demonstration as I have no idea how they will account for that variable.

Other Tidbits:

Group Health doc told me that PHR adoption at Group Health is now about 50%! That’s the highest percentage I have ever heard quoted. Hat’s off to them! He told me he loves it, his patients love it and that he has been doing email communications with his patients while sitting in on the various sessions. Hmmm, I hope those were just simple consultations and appointment reshedulings.
United Health executive told me that they have signed an agreement with Google Health and another will be signed with HealthVault any day now that will allow members to export their records into these personal health systems (PHS). As UHG is the second largest insurer in the country, this is some pretty big news and could give a substantial boost to these nascent platform plays.