Physician buy-in is essential for pay for performance.

The Centers for Medicare and Medicaid Services (CMS), employers, consumers, providers of all types, and health plans across the United States are taking a closer look at the value provided by our health care delivery system. There is a significant gap (50 percent) between the care patients require and the care they are rendered. In fact only 40 percent of patients receive care that is necessary and appropriate. (1)

Part of that gap is the result of a lag between the time new information becomes available to physicians and the time it is adopted. Studies have shown that after a major medical advance or a practice guideline is released, it takes about 10 years for doctors to change the way they practice medicine.

However, a health plan can reduce the "awareness curve" to anywhere between 12 and 18 months with early identification, proper feedback and systemic improvements. (2)

There is a national consensus that our health care system should establish physician reimbursement rates based on a balanced set of performance metrics. The Institute of Medicine report "Crossing the Quality Chasm" recommends sharing data with providers and paying for performance as cornerstones in closing the gap in clinical quality.

Sparked by employer initiatives such as Leapfrog and Bridges to Excellence, key industry leaders have implemented provider pay-for-performance programs designed to align incentives and encourage provider participation in quality care, customer satisfaction and efficiency improvement programs.

Voluntary or mandatory?

A pivotal question being posed as these programs roll out is whether physician participation should be mandatory or voluntary. Proponents of mandatory participation point to the need to engage all providers and their patients in clinical quality improvement programs. Supporters of voluntary participation speak of the need to engage motivated physicians and provide a level of autonomy for physicians.

Blue Cross and Blue Shield of Florida (BCBSF) took the latter position in its pay-for-performance program, Recognizing Physician Excellence (RPE[SM]). Working in collaboration with a physician advisory panel, BCBSF has created a compelling program that is achieving a significant participation rate from actively engaged physicians.

"I have always felt that if you incentivize doctors in the right way, you'll get better results," says David Felker, MD, a Delray Beach internist who is on the BCBSF physician advisory panel.

In 2004, working collaboratively with physician advisors, BCBSF designed and implemented an innovative pay-for-performance program.

Recognizing Physician Excellence is designed to recognize and reward physicians who are committed to providing quality care and excellent service. The RPE program supports the BCBSF mission of advancing the health and well-being of Florida's citizens. The program's objectives include:

* Improve the delivery of health care services--including quality, appropriateness and efficiency--that support favorable health outcomes for preventive care and chronic conditions.

* Improve the consumer's experience with the delivery system and help contain his/her medical costs.

* Encourage the use of knowledge and information technology.

* Enhance cultural excellence of our physicians through our Quality Interactions program (a CME program designed to enhance physician communication with diverse patient populations), recognizing that increasing knowledge and awareness of how cultural perspectives impact communication and health care can be a positive step toward closing the gap in health care disparities.

* Increase physician satisfaction by providing both financial and non-financial rewards, as well as access to health care tools/resources.

* Improve administrative efficiency in the delivery of health care.

In 2005, Phase I of the program rolled out to primary care physicians throughout Florida who have a substantial volume of BCBSF patients and who are part of a network of high-performing providers. These initial specialties included family practice, general practice, internal medicine, pediatrics, geriatrics and primary obstetrics and gynecology.

Performance is measured using a balanced scorecard of clinical quality, clinical efficiency and administrative efficiency.

Beginning in July of this year, physicians received awards based on high performance. In 2006, the program will expand to include awards for improved performance. That category is designed to reward physicians who improve their performance despite treating diverse and complex patient populations.

As the program evolves, incentives will combine with changes in health information technology (such as electronic health records) and tools that facilitate improvements in quality. Performance metrics will evolve as data become available and physicians achieve performance goals.

Incentive payments are based on physician performance compared to their peers. The average award is approximately five percent of professional claims or $3,000 per physician with a maximum of 15 percent or $12,000. (See Figure 1.)

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Reports are Web-based and distributed twice a year (January and July). The Web site contains tools and resources to assist in achieving goals.

As part of the program BCBSF medical directors, as well as other clinical and non-clinical staff, will work with physicians in their offices to provide guidance on opportunities for improvement.

Collaborative approach

The RPE team identified nearly 4,000 physicians to take part in Phase I. Physicians were asked to opt into RPE and agree to the program terms. They were provided with a program description, enrollment forms, an e-medicine interest card, a physician satisfaction survey and a physician practice demographics form.

To ensure program understanding, acceptance, and to gain insight and input, BCBSF conducted more than 50 statewide meetings with large, influential physician groups and held town hall meetings with a wide variety of eligible physicians in each community.

To date, nearly 2,828 (or 71 percent) of all invited physicians have enrolled in RPE. Significantly, these physicians touched 36 percent of BCBSF members who sought care in the prior year. Of those who attended or were represented at a key group or town hall meeting, more than 90 percent enrolled. (See Figure 2.)

Clearly, being given the opportunity to critique and provide direct input into RPE served to encourage physician participation.

BCBSF will continue involving physicians in the program. The RPE physician satisfaction survey will provide annual participant input and direction. Physician leaders throughout the state have been invited to provide ongoing input into program design. For example, the Florida Academy of Family Physicians has agreed to provide formal input into the selection of clinical quality indicators.

"When I get my report card from Blue Cross and Blue Shield, even now when I'm not financially rewarded for it, it's a really good feeling to know I'm doing well against my peers," says Felker. "I think I can speak for most doctors when I say we want to know where we're doing well and we want to know our deficiencies so we can do better."

So far so good

RPE has gained recognition throughout the industry as a model pay-for-performance program developed by physicians for physicians. By including physician input through the BCBSF Physician Advisory Panel, the program developed significant credibility in the provider community and with the news media.

Design and development have been highly collaborative with external programs including other Blues plans, BCBSA, CMS and Bridges to Excellence. In addition, employer groups have received the RPE program positively.

As BCBSF's medical director for RPE, I co-chair the BCBSA National Medical Management Forum's (NMMF) Quality Recognition Workgroup. This group has been tasked with helping to guide the selection of quality metrics across Blues plans that use available, claims-based measures tied to Ambulatory Quality Healthcare Alliance (AQA) measures, when feasible.

CMS will soon require physicians to report AQA measures as a condition for reimbursement increases. Plans can then leverage this information to improve the quality and efficiency of care across all of their networks to promote broader participation, greater flexibility in network arrangement and better access to physicians who demonstrate their accountability for the efficient management of the health and clinical quality of plan members.

The objective will be to use nationally defined metrics for quality and efficiency for BCBSF's locally-managed physician networks to enhance the value of the overall system's broad, deep networks.

In addition, these metrics will enhance the comprehensiveness of our networks by allowing Blues plans to embrace all physicians meeting these standards. This will equip physicians, customers and members with the information they need to make decisions that will ultimately lead to better quality and more affordable health care everywhere in the U.S.

In the end, pay for performance is here to stay and will play an ever increasing role in physician payment from private and public payers. Active physician participation in the design and implementation of these programs should yield optimal results and go a long way toward the goal of closing the "quality chasm."

Robert S. Mirsky, MD, MMM, medical director of Blue Cross and Blue Shield of Florida, is responsible for introducing and implementing the "Recognizing Physician Excellence" program to physicians throughout the state. He can be reached at 941-378-7334 or [e-mail]

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References

1. McGlynn E.A, Asch SM, Adams J, Keesey J, Hicks J. DeCristofaro A, Kerr E A. "The Quality of Health Care Delivered to Adults in the United States," New England Journal of Medicine, 348:26 p. 2643.

2. Health Benchmarks, Inc. www.healthbenchmarks.com

By Robert S. Mirsky, MD, MMM, FAAFP 

RELATED ARTICLE: Clinical quality

Here are metrics that are intended to consider basic clinical measures that can lead to better outcomes for preventive care and chronic conditions. This area will expand as RPE matures.

* Women's health and preventive measures (cervical cancer and breast cancer screening)

* Disease management measures (diabetes, asthma, hyperlipidemia)

Clinical efficiency

This measurement focuses on optimizing member out-of-pocket costs and resources.

* Formulary and generic prescribing rate

* Targeted disease ER avoidance (asthma, diabetes)

* Participation in BCBSF's e-Medicine program using RelayHealth (efficient, online physician-patient communication; e-prescribing and prescription error reduction)

Administrative efficiency

This area focuses on optimizing and streamlining administrative processes for members, physicians and BCBSF.

* Use of electronic claims submission

* Updated directory information

In Phase II (2006), customer satisfaction will be added to the scorecard.

Customer satisfaction

This measurement is designed to incentivize physicians to favorably influence the care experience for BCBSF members.

* Industry and BCBSF consistent surveys (access to care, outcomes of care, quality of service, cultural competence, overall care experience)

* Measured using a 19-question electronically administered physician-specific survey

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Also in Phase II, high volume specialties will be added to the program, metrics will expand and the focus on preventive care, cardiovascular disease management and pediatrics will increase. As an additional incentive to participate, in Phase II, the BCBSF Provider Directory will identify those physicians who are enrolled in RPE.