08 Jun Experts spar over incentives for health-care providers
Madison, Wis. — An executive panel on Wednesday night told health-care providers, vendors and decision-makers that agreeing on standard performance measurements – and standard payment for performance – could create better, or worse, health care.
John Kelly, principal of Grindstone Consultants, said that pay-for-performance takes broad agreement from health-care stakeholders on what is most valuable and what systems should be used to measure and reward performance. Such agreement could potentially address the differences in care from place to place. “There’s a lot of unexplained variation going on in health care,” said Kelly, the former senior vice president of systems for Gundersen Lutheran Health System.
“When we have the ability to drive sustained breakthroughs … in health care services, it’s going to occur when there are common or standard performance measures.”
But not all physicians agree that payment incentives should follow certain measures of performance – 80 percent of a practice’s patients receiving immunizations on schedule, for instance. The problem is not so much the incentives to do better at certain tasks, but what happens to the rest of the physician’s practice.
Barry Chaiken, a doctor and associate chief medical officer of BearingPoint, said that incentives always have some kind of unintended effects. “What are the risks,” he asked, “if we implement pay-for-performance, that the incentives produce poor outcomes?”
A simple example is the incentive to treat diabetic patients effectively with both treatments and patient education. It sounds like it could only produce better outcomes – but that’s for diabetic patients.
“The physician is less focused on something else,” Chaiken said.
One of the tools behind pay-for-performance is the technical ability to reliably track patient care and progress across a potential array of different health-care practices. The electronic medical record promises physicians that ability, if it can fully get off the ground.
Carl Christensen, CIO of Marshfield Clinic, said the clinic’s use of electronic medical records allows it to focus heavily on preventative care. Physicians can be alerted when patients with conditions that require regular checkups need to be contacted, for instance.
Christensen said pay-for-performance helps hold the quality of care to high standards while health-care systems undergo cost-cutting measures. “If all you’re doing is lowering costs, it could just become a rationing,” he said.
The clinic is participating in a demonstration program by the Centers for Medicare and Medicaid Services, or CMS, which measures 34 quality criteria. Most of them look at what percentage of patients with particular conditions get agreed-upon education, preventative services or prescriptions.
If Marshfield meets these criteria while lowering costs, it gets financial incentives in return. “What we figured out is: The best way to lower costs for these patients is to keep them healthy and keep them out of the hospital,” Christensen said.
The incentive to keep patients out of hospitals might not be the same at a system of hospitals, of course, and the differing impact of incentives leads some to doubt them. If a patient’s history is not easily at hand, or if incentives encourage each practice to perform procedures for itself, rather than relying on the history, patients could face a panalpy of testing.
Already, if records are on paper, a patient may have to be readministered a test whose results are sitting in a filing cabinet miles away. But the wrong incentives could cause the same problem, said Seth Foldy, a professor at the Medical College of Wisconsin who recently ended a six-year term as commisioner of health for Milwaukee. The disconnect could happen if incentives are given for performing processes, rather than keeping patients healthy.
“If a process outcome is that every patient gets a mammogram, and she goes to 10 physicians, she, or he, gets 10 mammograms, which most of us could not consider quality care,” Foldy said.
“What no one’s figured out is: How do you pay a collaborative for doing a good job?” he added.