Pay for Performance and Physicians may be like taking Cats for a Walk

 

The look of cooperation

Medicare continues to move forward with its PRQS "value-based" fee schedule modifier that will adjust physician payments up or down by 2% and 1%, respectively. 

As the Disease Management Care Blog understands it, 2015 physicians' quality and cost data will be compared to peers, and the docs who are above and below the mean will be correspondingly financially rewarded or dinged starting in 2015.  While the American Medical Association continues to quibble over the details, this Affordable Care Act pay-for-performance (P4P) train has left the station.

Unfortunately for CMS, plenty of research suggests that it remains an open question whether PRQS will have much of an impact. For example, findings from this Ontario study indicate that incentives tend to reward physicians who have already achieved the quality thresholds, doing little for the docs who are behind.  Additional research shows physicians may not agree with the underlying methodology and distrust the reliance on insurers' data, leading to a willful disregard of the incentives.  And then there's this expert survey that suggests that the effort it takes to achieve low single digit digit changes in income may be viewed as not worth the trouble.

The DMCB also thinks there may be another under-recognized issue at stake. While fee schedule changes in the 1% to 2% range can make a big difference to large hospital-physician organizations, that money, thanks to these organizations' byzantine internal accounting and transfer pricing, is unlikely to trickle down in a meaningful way to their employed physicians' paychecks. 

Ouch.

Physicians and P4P may turn out to be like cats and going for a walk.



Image from Wikipedia

From P4P to Pay Patients for Performance (P4PP)?

Joanne Wu, writing in the Annals of Family Medicine, suggests that we dismantle the health insurers' "pay for performance" ("P4P") programs in favor of "pay patients for performance" (PP4P).  As blood pressure control, cholesterol treatment, cancer screening rates or fitness rates increase, she proposes that patients receive "health care credits" in the form of lower co-pays, discounts or premium reductions.

Good idea, says the  Disease Management Care Blog, but:

1) Long standing regulations stand in the way. Health insurance regulators generally frown on programs that compromise community-rated risk pooling that gives everyone the same benefit for the same price.  ERISA-protected plans, on the other hand, have greater latitude in flexing their insurance benefits. 

2) Politics stand in the way. Opponents argue that persons less well off will be unfairly disadvantaged by wellness incentives.  You can read more about that here. 

3) Doctors stand in the way. Last but not least, insurers generally fund P4P by diverting the money from the providers' inflation-adjusted or market-driven fee schedule increases.  In other words, taking P4P money from the docs and giving P4PP to the patients ain't gonna easily happen.

That being said, the DMCB thinks Dr. Wu may be onto something.  She recommends a pilot be tried in a small community.  Given the downstream savings, we'd be foolish to not take every advantage we can to achieve patient buy-in, and a pilot sounds like a grand idea.

How Can Care Management Programs Manage Physician Incentives?

One ingredient for physician cooperation?

Years ago, when the Disease Management Care Blog was helping to lead a care management program, it was paired up with a nurse-administrator who was troubled by the notion that docs should get paid to sign-off on a disease management care plan. Why, it was asked, should docs get any extra compensation to do something that's a fundamental part of caring for patients?

It listened politely to its colleague's input.  After a careful review of all the issues, risks, benefits and alternatives, the physician-DMCB decided to compromise by paying the docs to sign-off on the care plans.

Drs. Nikola Biller-Andorno and Thomas H. Lee, writing in the March 14 New England Journal, point out that that physician enticements are far more complicated than shekels for signatures. They think economic incentives in health care are a complex mix of "traditional," (social status) "self-interest, (one example is money) "affective" (being appreciated) and "shared purpose" (for the greater good) motives.  They also suggest that they are unavoidable.

A nurse care management administrator might as well join 'em rather than fight 'em.

Armed with that insight, it's easier to contrast the underlying cultures of a non-for-profit community health center versus a for-profit hospital chain. It's also easier to understand that performance measures can not only appeal to self-interest (as in pay for performance) but to the "affective" reward of being given an excellent rating by a community of colleagues.  The authors also point out that a sense of shared purpose cannot be underestimated, since it speaks to the "core principles of the medical profession."

The DMCB's insight here is that there is no single incentive "lever" that can change physician behavior.  Rather, the best approach to incentives is to capitalize on all four incentive domains.  What's more, if "shared purpose" is undervalued, physicians are more likely to feel dissed and ignore the best laid incentive plan.

It turns out paying the docs was the right thing to do as well as appealing to their sense of shared purpose.  What the DMCB and nurse administrator should have done was to also look for some way to leverage the other domains of social status (perhaps a recognition program) and being appreciated (asking a lead physician to express appreciation for the extra work.

Image from Wikipedia