Pay for Performance Still Faces Slow Going

Early experiments in pay-for-performance and other quality- and incentive-based healthcare reimbursement systems have been promising, but the concept will never reach its full potential to transform care until more physicians have access to advanced health-IT, say several program leaders.

"Pay for performance is never going to achieve the value we want unless it's linked tightly with health-IT. Period. It's just not going to happen," said Carolyn Clancy, M.D., director of the federal Agency for Healthcare Research and Quality (AHRQ), speaking at a P4P symposium in Washington recently.

Clancy said the recent presidential order calling for increased transparency in healthcare pricing and quality (see and new regulations to ease restrictions on hospitals providing technology to physicians are "lowering the risk of investment" for physicians. Clancy also said her agency is involved in or aware of more than 100 pay-for-performance projects, encompassing as many as 53 million Americans—a number she expects to grow to 85 million by 2008.

However, with electronic medical records (EMRs) in just 15 percent to 20 percent of physician practices — and many EMRs lacking reporting tools — collecting quality data has been a challenge, Clancy said. The AHRQ director insists that only a single set of standards and a single set of performance measures for a given medical condition will help technology developers add real-time feedback to practitioners to facilitate clinical decision support and unleash the true power of the EMR.

"If it's all left to individual programmers, it's not going to be the case," Clancy cautioned. 

The hard part, according to Clancy, is to develop a model of shared accountability that is fair to patients, clinicians, and payers alike. "We've got to have guidelines that are written from the ground up in ways they can actually be incorporated into clinical decision support," Clancy said. Furthermore, Clancy added, evidence must be relevant to the individual patient at the point of care.

Jon Shematek, vice president for quality and medical policy at CareFirst BlueCross BlueShield in Maryland, the District of Columbia, and Northern Virginia, reported some success at the halfway point of a three-year, $4.5 million pilot program, but he still lacks the data he needs to sell pay-for-performance on a wide scale. "Some of us are very encouraged and enthusiastic about the anecdotes we've heard, but my board isn't going to be willing to fork up a load of money indefinitely," Shematek said at the symposium, part of the Third Health Information Technology Summit.

Louisville, Ky., family practitioner A. O'Tayo Lalude, a participant in the Bridges to Excellence P4P program, said that doctors essentially act as teachers to their patients, and thus need standards and uniformity to be effective. "To be able to teach, we have to have a flat field," Lalude said.

The Internet has leveled the field in the past decade, but there are so many disparate guidelines in medicine, even among those listed in AHRQ's National Guideline Clearinghouse. "If I see evidence of it, if you make it flat for me so we are reading the same thing in Madras, India, as we are in Louisville, Ky., that's the issue here," according to Lalude. "The universal language of sharing is metrics."

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