Pay-for-performance program focuses on Web-based quality data.

One can hardly pick up a copy of any medical publication without finding pay-for-performance (P4P) plans boldly presented. Whether in medical journals, the American Medical Association News, industry trade publications or even The Physician Executive, it seems P4P is everywhere.

The general consensus is that P4P programs are proliferating rapidly, albeit without much compelling evidence of their worth. There is serious concern on the part of many providers about basic issues of fairness in these programs.

The American Medical Association recently expressed its reservations to the Centers for Medicare and Medicaid Services (CMS) about their proposed system and its apparently onerous reporting requirements, but has agreed to help develop a list of acceptable quality measures for inclusion.

Despite these concerns early reports of success with P4P in California spawned an explosion in such programs that clearly suggests P4P has reached the tipping point and is here to stay, at least for the time being.

Starting from scratch

Joining this trend was Clear Choice Health Plans, a provider-sponsored organization in Bend, Oregon.

As the organization grew to serve more than 40,000 members, it became necessary to develop more sophisticated mechanisms such as pay-for-performance programs to complement existing quality assurance, case management and utilization management processes.

The first step was to get a better idea of what P4P programs were out there. Clear Choice found that, although there are differences between existing programs, they all share certain similarities, namely a focus on discreet clinical measures, similar to HEDIS, to serve as surrogate markers for quality.

Rates of preventative screening procedures, diabetes measures and lipid determinations predominate. Primary care providers are the prime targets of these programs mainly because no one has yet devised an acceptable set of specialty-specific parameters. The selected metrics are chosen primarily because that is what can be measured from claims data, imperfect as that may be.

Some programs place significant data gathering and reporting requirements on providers, often engendering their displeasure. Finally, nearly all P4P programs reward or penalize physicians depending on where they rank compared to others.

Finding flaws

Despite the fact that nearly everyone is developing P4P programs, most organizations freely admit the plans' limitations. Measuring a baker's dozen of discreet clinical parameters is good, but does it fundamentally improve quality or change practice habits? Won't providers simply "teach to the test?"

If physicians know they are being measured on the rate they obtain glycohemoglobin levels in diabetics, won't they just be sure to measure those more often? Will that really change the quality of care overall?

It's not as if diabetes, hypertension and hypercholesterolemia are the only disorders physicians treat. Shouldn't the goal be to change the way medicine is practiced and improve the overall quality of care?

Only rewarding the better performing physicians and penalizing poorer performers may not raise the overall quality of care. Disenfranchising the bottom half may not be particularly motivating.

Onerous reporting requirements placed on providers take them away from their patients. Poorly chosen metrics, misaligned incentives and inadequate compensation for the time required can derail a P4P program.

Creating a better P4P model

If the goal of P4P is truly meant to drive improvement in the quality and value of care, and hold providers accountable for outcomes, a program that fundamentally changes how physicians work is needed.

There must be a systematic change in practice patterns. A handful of quality measures is unlikely to do that. But the wholesale adoption of clinical practice patterns based on the very best evidence the medical literature has to offer just might.

Rather than basing a P4P program on narrowly focused metrics, Clear Choice developed a unique and innovative program that attempts to change practice patterns more globally by encouraging greater adoption of evidence based medicine and self-directed quality improvement.

Instead of calling it a pay-for-performance plan, Clear Choice chose to call it the Clear Choice Quality Awards program. This reflects the underlying philosophical commitment to making this program truly one that recognizes and rewards physicians for their dedication to quality medical care. Financial utilization measures are not the primary focus of the program.

The program has three main measures emphasizing the importance of evidence-based decision making, appropriate guidelines for imaging, and improvement in clinical quality measures. Specifically, each of the following components will count toward 1/3 of the score-card for a potential award.

* Use of UpToDate.com as a reference tool.

* Use of the American College of Radiology's Appropriateness Criteria/radiology utilization.

* Improvement in clinical quality metrics on a report card.

Are you up to date?

The heart of Clear Choice's program is use of www.UpToDate.com. If you are not familiar with this online resource, you are missing out on one of the biggest breakthroughs in medical practice since the advent of the Internet.

UpToDate was the brainchild of Burton Rose, MD. He realized over 10 years ago that the pace of new information was accelerating so rapidly that the traditional methods we use to stay current, such as reading journals and attending CME programs, simply don't work. Searching Medline is very time-consuming and impractical for a busy practitioner.

Rose created an online service in which expert physicians continuously review over 350 medical journals searching for quality evidence. His idea rapidly took off. Today, UpToDate has over 10,000 users and 7,000 topic summaries spanning nearly all of clinical medicine. Once physicians try it, they like it. In fact, over 90 percent of subscribers report that using UpToDate:

* Changes their management

* Changes their diagnostic testing

* Is an efficient way to keep up

* Helps them provide the best care

* Makes them more comfortable with their decisions

* Makes them a "better doctor"

* Is faster than other means of obtaining information

Studies reveal that 80 percent of UpToDate searches result in improved care of the patient. Vanguard Medical Associates, a large multi-specialty group in Massachusetts found that using UpToDate:

* Confirmed plan/knowledge

* Avoided phone calls/curbside consults

* Suggested correct testing

* Raised additional considerations

* Changed choice of drug

* Led to decision to discontinue drug

* Avoided specific testing

* Caused clinician to intervene rather than wait

* Avoided a referral

* Avoided a medication error

Clear Choice is convinced that physicians who use UpToDate are better diagnosticians and practice the highest quality medicine, so use of this resource was embedded into the P4P program.

Image is everything

The second component of the Clear Choice program is the American College of Radiology's Appropriateness Criteria Web site (www.acr.org). Imaging has become so complex that even radiologists can have difficulty keeping up with the latest recommendations. It is almost impossible for a non-radiologist to do so.

Having a resource such as the ACR Appropriateness Criteria with its proven benefits addresses a need that is lacking in most other P4P frameworks, namely the need to improve imaging.

Report cards

The final component of the Clear Choice program is the provider report card. Developed in collaboration with Curt Hatch, president of ManagedCare.com, this instrument provides physicians with a comprehensive and detailed look into their practices.

With a robust list of key performance indicators depicted in both graphic and tabular formats, the report card is visually appealing and easy to use. It also offers extensive drill-down so that providers can obtain patient-level and other details that allow them to understand the statistics being captured.

Providers can view their report card by logging into ManagedCare.com through the provider portal on the Clear Choice Web site. A list of key performance indicators and screen shots of the report card include:

* Patient summary demographics

* Evaluation and management coding summary

* Emergency department utilization

* Bed days

* Referral data

* Lab tests per member

* Lab utilization

* Generic utilization

* Antidepressant utilization

* MRI utilization

* CT utilization

* Quality measures

* Efficiency percentile ranking

The real-time feedback contained in these report cards gives Clear Choice providers the tools necessary to monitor and improve their performance.

Clear Choice complemented the profiles with a bonus program. Distributions are tied to the individual physician's attainment on the three measures, 1/3 of the total bonus for each.

The organization anticipated enrolling a very small number of providers, perhaps only 50 this year. But within a few months, it was apparent that enrollment would exceed expectations.

Fearing dilution of the bonus pool, a decision was made to close enrollment on June 1, 2006. However, several providers protested and enrollment was extended to July 1.

Ultimately, 118 providers successfully registered for the program. Roughly 18 percent of Clear Choice's contracted providers are actively participating. Clear Choice monitors their activity and visits to UpToDate.com.

As of September, the 100 enrolled providers had logged onto UpToDate.com over 600 times, the ACR Appropriateness Criteria Web site nearly 150 times and viewed their score cards over 200 times.

The extent of provider interest was unanticipated and demonstrated that it is possible to craft pay-for-performance programs that providers will accept. Further, given data from UpToDate demonstrating that users improve the quality and efficiency of their medical care, Clear Choice believes the program offers an excellent value proposition for improved clinical quality.

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Michael A. Patmas, MS, MD, MMM, FACP, CPE, FACPE, is the vice president of medical affairs and medical director of Clear Choice Health Plans in Bend, Ore., and a clinical assistant professor of medicine at Oregon Health Sciences University. He can he reached by phone at 541-330-8113 or by e-mail at [e-mail]

Rowena Rosenblum is the manager of the medical affairs department at Clear Choice Health Plans in Bend, Ore. She can be reached by phone at 541-385-5315 or by e-mail at [e-mail]

Curt Hatch is the president of ManagedCare.com in Grand Junction, Colo. He can be reached by phone at 970-254-2914 or by e-mail at [e-mail]

Michael A. Patmas, MS, MD, MMM, CPE, FACP, FACPE, Rowena Rosenblum and Curt Hatch, CFA, MBA 

Figure 1 Growth in Number of Pro-for-Performance Programs

Number of Programs

2003      35
2004*     84
2005**   104
2006***  160

*Data as of November 2004
**Data as of March 2005
***Projected by Med-Vantage

Source: Med-Vantage (2005), Rosenthal, MB etal. (2005) Journal of the
American Medical Association, Dudley, RA (2005) Journal of the American
Medical Association.

Note: Table made from bar graph.