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Pay-for-Performance The Impact of Pay-for-Performance It has been projected that up to 30% of Medicare payments will be performance-related in the next ten years. Pay-for-performance or “P4P”, is based on the concept of payment according to improvements in care made by health care systems and providers. It has been called a movement toward the goal of the “quality-driven health care system.” This concept was developed in an attempt to revise payment systems and to reward quality care. Models were tested for three years through seven experimental projects. Results from these tests were released in 2005 suggesting that there was an improvement in the quality of health care provided. Specific results reported included improved preventive health care access, implementation of electronic medical records, and closer monitoring of care for chronically ill patients. Large health care insurers in the United States have already implemented plans with varying success. There is some variance in the results, and one reason for this could be the lack of consensus on which indicators to tie to performance and payment. Although there are limitations on pay for performance’s ability to address problems and burdens in the healthcare system, larger insurers have stated that it is a “step in the right direction.”[ii]
Key points regarding pay-for-performance are as follows:
Quality
driven healthcare
Improvements
seen in preventive health care access and close monitoring
Currently in place in some insurance and expanding
Diabetes
Diabetes is one of the disease states of interest for the implementation of pay for performance systems at all levels of health care.
The application of pay for performance programs in diabetes will use existing guidelines to provide the indicators of improved diabetes care. Pay for performance contracts would reward providers and health systems that follow the guidelines and reduce their focus on the less critical aspects of care. Clinical indicators have been the primary focus, but efficiency indicators are used by at least half of the programs reported in 2005.[iii] Diabetes will be a complex case for pay for performance because there are so many coexisting diseases, such as cardiovascular and renal diseases, that can affect the success of clinical care efforts. Because of this, guidelines on management of blood glucose, lipid disorders, and hypertension are likely to receive the most attention. One of the pitfalls pointed out in a 2006 article is the potential for a conflict of interest when it comes to available formulary medications. In addition, there may be less stellar results in routine clinical care than in the research used to support guidelines. Pay for performance may have a positive influence to get evidence-based guidelines implemented in clinical settings and to improve overall patient health status. But, as one article points out, if the payment system makes it difficult to achieve the rewards, pay for performance diabetes patients may be excluded from clinical practices the same way that other unprofitable patients have been excluded to reduce financial risk.[iv]
Summary
Diabetes affects a growing number of people in the United States with significant health and financial costs. With around 21 million people living with diabetes and 41 million people living with prediabetes, health care aimed at the prevention of disease progression and complications has been suggested to improve health and reduce costs. Screening can be undertaken in people with certain risk factors for the development of diabetes in an effort to prevent the progression and institute early preventive strategies. Diet and exercise therapy can delay the progression from prediabetes to diabetes in nearly 60% of cases. One study suggested that aggressive intervention including diet, exercise, and medication therapy to improve impaired fasting glucose and impaired glucose tolerance tests may fully prevent the progression to diabetes. Treatment of type 2 diabetes emphasizes self-management strategies, encompassing education, diet/nutrition, physical activity and exercise, stress management, and medications. Ongoing support is a key factor in the successful maintenance of the beneficial effects on glucose control through self-monitoring. Medication strategies include monotherapy, combination therapy, and the use of individualized adjunctive medications. Monotherapy with oral anti-diabetic drugs is indicated when HbA1c levels are between 6% and 7%. If blood glucose does not reach target levels or if HbA1c levels are between 7% and 8%, combination therapies can be used. If HbA1c levels are at 8% to 9%, more aggressive or intensified therapies can be used. Insulin therapy may be initiated if target levels of glucose are not achieved, or if HbA1c are very high at >10%. Adjunctive medications act on other hormones and feedback systems to result in lower blood glucose levels and weight loss.
[i] National Conference of State Legislatures. State Laws Mandating Diabetes Health Coverage. November 2007. Available at: http://www.ncsl.org/programs/health/diabetes.htm. [ii] PRWeb. Pay for performance in healthcare gets an “incomplete’ report card says PricewaterhouseCoopers report. August 2007. Available at: http://www.prwebdirect.com/releases/2007/8/prweb548485.php. [iii] Endsley S, Baker G, Kershner BA, Curtin K. What family physicians need to know about pay for performance. Family Pract Manage. 2006;13(7). Available at: http://www.aafp.org/fpm/20060700/69what.html. [iv] Leichter SB. Pay-for-performance contracts in diabetes care. Clinical Diabetes. 2006;24:56-59. |
