pay for performance (“p4p”) bangkok december 2009 december 2009
TRANSCRIPT
Pay for Pay for PerformancePerformance
(“P4P”)(“P4P”)BangkokBangkok
December 2009December 2009
1. What Is It?1. What Is It?
Performance IncentivesPerformance Incentivesto Households and/or to Households and/or
ProvidersProviders ““Demand side”Demand side”
Conditional Cash Conditional Cash Transfer (CCT) Transfer (CCT) Programs ( mostly LAC)Programs ( mostly LAC)
Households receive Households receive income transfersincome transfers
preventive care servicespreventive care services Maternal and child careMaternal and child care Money and food to Money and food to
motivate TB/HIV patients motivate TB/HIV patients to complete treatment.to complete treatment.
““Supply side”Supply side”
Paying PremiumsPaying Premiums ArgentinaArgentina
Providers “Process” Providers “Process” Indicators = Indicators = Improved OutcomesImproved Outcomes
Bonus SystemsBonus Systems Service Packages Service Packages
(typically primary (typically primary care)care)
Afghanistan,Haiti,RwAfghanistan,Haiti,Rwanda.anda.
Performance IncentivesPerformance Incentivesto Households and/or to Households and/or
ProvidersProviders ““Demand side”Demand side”
Conditional Cash Conditional Cash Transfer (CCT) Transfer (CCT) Programs ( mostly LAC)Programs ( mostly LAC)
Households receive Households receive income transfersincome transfers
preventive care servicespreventive care services Maternal and child careMaternal and child care Money and food to Money and food to
motivate TB/HIV patients motivate TB/HIV patients to complete treatment.to complete treatment.
““Supply side”Supply side”
Paying PremiumsPaying Premiums ArgentinaArgentina
Providers “Process” Providers “Process” Indicators = Indicators = Improved OutcomesImproved Outcomes
Bonus SystemsBonus Systems Service Packages Service Packages
(typically primary (typically primary care)care)
Afghanistan,Haiti,RwAfghanistan,Haiti,Rwandaanda..
Payment Incentive Performance Outcomes/Goals
Paying Providersbased on performance (P4P)
What is it? Measure performance of participating providers to set financial incentive for improving performance, leading to better outcomes
Payment Incentive Performance Outcomes/Goals
Paying Providersbased on performance (P4P)
What is it? Measure performance of participating providers to set financial incentive for improving performance, leading to better outcomes
Outputs
Payment Incentive Performance Outcomes/Goals
Paying Providersbased on performance (P4P)
What is it? Measure performance of participating providers to set financial incentive for improving performance, leading to better outcomes
Payment Incentive Performance Outcomes/Goals
Paying providers based on performance (P4P)
What is it? Measure performance of participating providers to set financial incentive for improving performance, leading to better outcomes
Why P4P? Improved Outcomes In the process….reduce costs, improve quality and
efficiency/equity
2. Designs and Measures2. Designs and Measures
Pay-for-Performance (P4P)Pay-for-Performance (P4P)for physicians and hospitalsfor physicians and hospitals
There are different P4P designsThere are different P4P designs
Why?Why? Different information technology Different information technology
capabilitiescapabilities Data availabilityData availability Willingness of providers to participate Willingness of providers to participate
Pay-for-Performance (P4P)Pay-for-Performance (P4P)for physicians and hospitalsfor physicians and hospitals
There are different P4P designsThere are different P4P designs Why?Why?
Different information technology capabilitiesDifferent information technology capabilities Data availabilityData availability Willingness of providers to participate Willingness of providers to participate
P4P is more common for outpatient P4P is more common for outpatient care than for hospital carecare than for hospital care Preventive and primary care servicesPreventive and primary care services
Types of Measures: Start Types of Measures: Start HereHere
Basic AccessBasic Access Example: operating hoursExample: operating hours
Preventive ServicesPreventive Services Number of enrollees that have a prepared annual Number of enrollees that have a prepared annual
health planhealth plan Breast cancer screening (mammograms)Breast cancer screening (mammograms) Cervical cancer screening (pap smears)Cervical cancer screening (pap smears) Retinal eye exams for diabeticsRetinal eye exams for diabetics Well-child examsWell-child exams Childhood immunizations Childhood immunizations
Institutional CapacityInstitutional Capacity Implementation of a financial management systemImplementation of a financial management system
Source: Rena Eichler, WB, 2003
Types of Measures: Types of Measures: Extend to More System-Extend to More System-
BasedBased Effective management of chronic casesEffective management of chronic cases
Percentage of diabetics with controlled lipid levels (LDL levels Percentage of diabetics with controlled lipid levels (LDL levels less than 130mg/dL)less than 130mg/dL)
Health educationHealth education % of smokers who participate in smoking cessation workshops% of smokers who participate in smoking cessation workshops
Hospital qualityHospital quality Infection ratesInfection rates
Control excessive utilizationControl excessive utilization Percentage of prescriptions that are genericPercentage of prescriptions that are generic
UK: Examples of Measures for Chronic UK: Examples of Measures for Chronic CareCare
Asthma % of patients with asthma who have had an asthma review in previous 15 months
Cancer % of patients with cancer reviewed within 6 months of confirmed diagnosis
Chronic obstructive pulmonary disease (COPD)
% of patients with COPD with diagnosis confirmed by spirometry and reversibility testing
Coronary heart disease (CHD)
% of patients with CHD whose last blood pressure measurement was 150/90 mm Hg or less
Diabetes % of patients with diabetes whose last blood pressure measurement was 145/85 mm Hg or less
Hypertension % of patients with hypertension with last blood pressure measurement was 150/90 mm Hg or less
Hypothyroidism % of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months
Mental health % of patients with severe long-term mental health problems reviewed in the preceding 15 months
Source: Pay for Performance Program, UK. www.nejm.org
3. Global Experience3. Global Experience
95
7972
58
43 41
30
0
25
50
75
100
UK NZ AUS NET GER CAN US
Percent reporting any financial incentive*
Primary Care Doctors’ Reports of Any Financial Incentives
Targeted on Processes/Quality of Care, 2006
* Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activitiesData: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
United StatesUnited States
Started in private sector (80% of HMOs use) Started in private sector (80% of HMOs use)
MedicareMedicare Bonuses to HospitalsBonuses to Hospitals
Top 20% for processes related to specified treatmentsTop 20% for processes related to specified treatments Joint replacement, CABG, heart attack, heart failure, pneumonia Joint replacement, CABG, heart attack, heart failure, pneumonia
MedicaidMedicaid 115 P4P programs in States (50 million lives)115 P4P programs in States (50 million lives)
Flat bonus or premium, withholds, publication of provider Flat bonus or premium, withholds, publication of provider scoresscores
United States (Maryland)United States (Maryland)
Incentives for reducing actual number of Incentives for reducing actual number of complications complications afterafter hospital admissions hospital admissions linked to poor quality of care, such aslinked to poor quality of care, such as
Urinary tract InfectionUrinary tract Infection Septicemia (infection in blood)Septicemia (infection in blood) Collapsed lungCollapsed lung
52 categories52 categories
Since 2004, the NHS of the Since 2004, the NHS of the UK introduced P4PUK introduced P4P
for Family Practitioners for Family Practitioners NHS committed $3.2 billion in additional NHS committed $3.2 billion in additional
funding over 3 years for P4P program funding over 3 years for P4P program
146 indicators for P4P146 indicators for P4P Immunizations, well-child careImmunizations, well-child care 10 chronic diseases10 chronic diseases organization of careorganization of care patient counseling and experiencepatient counseling and experience Postgraduate education allowance Postgraduate education allowance
P4P: Impact on QualityP4P: Impact on Qualityof Community Services in England of Community Services in England
Mean Scores for Clinical Quality at the Practice Level for Aspects of Care for Coronary Heart Disease, Asthma, and Type 2 Diabetes That Were Linked with Incentives and Aspects of Care That Were Not Linked with Incentives, 1998–2007.
Quality scores range from 0% (no quality indicator was met for any patient) to 100% (all quality indicators were met for all patients).
Source: S. Campbell et al., “Effects of Pay for Performance on the Quality of Primary Care in England,” N Engl J Med 2009;361:368-378.
Overall Results MixedOverall Results Mixed (US and UK) (US and UK)
Some Improvement in quality but often modest Some Improvement in quality but often modest (<5%) in terms of outcomes(<5%) in terms of outcomes
Not clear who benefits (US HMO PacifiCareNot clear who benefits (US HMO PacifiCare Top quintile of provider performanceTop quintile of provider performance Lowest quintile (not often)Lowest quintile (not often)
Administrative costs higher (UK: check the box). Administrative costs higher (UK: check the box). Family practitioners (FP) employed more nurses and Family practitioners (FP) employed more nurses and administrative staff and increased use of electronic administrative staff and increased use of electronic medical recordsmedical records
Questions Remain: e.g., does it take away from non-Questions Remain: e.g., does it take away from non-bonus areas of care?bonus areas of care?
Results from 1Results from 1stst Year of P4P Year of P4Pin the UKin the UK
Financial incentives affect physicians’ behaviorFinancial incentives affect physicians’ behavior But no way to establish how much of behavior But no way to establish how much of behavior
change is due to P4Pchange is due to P4P
Providers attained a median of 96.7% of available points Providers attained a median of 96.7% of available points compared to 75% predictedcompared to 75% predicted Targets were too easy to achieveTargets were too easy to achieve
P4P program increased gross income of average family P4P program increased gross income of average family practitioner by $40,200 per yearpractitioner by $40,200 per year
As a result, cost to payer was considerably more than As a result, cost to payer was considerably more than expectedexpected
Smaller FP practices have merged due to administrative Smaller FP practices have merged due to administrative pressures from new P4P contractpressures from new P4P contract
BrazilBrazilGlobal budgets allocated in monthly installments
A 10% retention bonus fund for compliance with performance indicators includingGood quality (e.g., hygiene and sterilization practices)Patient satisfaction (no overcharging and perceptions of quality)No fraud (ghost patients)
Hire and fire staffing policies; Staff mix flexibility/Salary adjustments/bonuses and staff/ promotions flexibility
OutcomesImprovement in quality
general and surgical mortalitylower infection rates
Higher efficiency improved bed turnover rates, occupancy rates, length of stay physician hours expenditure per admission
HaitiHaiti Providers paid fixed fee plus bonus for achieving Providers paid fixed fee plus bonus for achieving
performance targetsperformance targets
Measures:Measures: increase in % of children < 1 who are fully immunizedincrease in % of children < 1 who are fully immunized increase in % of pregnant women who receive at least 3 increase in % of pregnant women who receive at least 3
prenatal care visitsprenatal care visits for each indicator, a baseline measure determined at for each indicator, a baseline measure determined at
the beginning of a contract period and a target for the beginning of a contract period and a target for improvement is established. improvement is established.
Subcontracts clearly established targets, describe how Subcontracts clearly established targets, describe how performance will be measured, and determine the award performance will be measured, and determine the award fee associated with attainment of each target. fee associated with attainment of each target.
ResultsResults 2.7 million people 2.7 million people Increased immunizations by 24%Increased immunizations by 24%
4. Design Issues4. Design Issues
An Initial ListAn Initial List
Target physicians or facilities?Target physicians or facilities? Primary or specialists?Primary or specialists? Carrots or sticks?Carrots or sticks? Performance thresh-holds be Performance thresh-holds be
Absolute changes?Absolute changes? Relative scoring rank?Relative scoring rank?
New Funding? Where will funding New Funding? Where will funding come from?come from?
Different Methods to PayDifferent Methods to Pay Based on Performance Based on Performance
WithholdsWithholds Withhold about 5% of reimbursement. Return all Withhold about 5% of reimbursement. Return all
or proportion or proportion
BonusBonus Provide mean rewards ranging from 5-20% of total Provide mean rewards ranging from 5-20% of total
reimbursement reimbursement Reward top-rated providers onlyReward top-rated providers only
Quality grantsQuality grants Provide funds to provider for specific quality Provide funds to provider for specific quality
improvement project (e.g. access to rural improvement project (e.g. access to rural residents)residents)
ThresholdThreshold Link at least 10% of compensation to change Link at least 10% of compensation to change
behaviorbehavior
What is Financial RiskWhat is Financial Risk for providers under P4P? for providers under P4P?
Providers can gain incremental revenue from Providers can gain incremental revenue from successful performance without large financial risks successful performance without large financial risks under P4P programsunder P4P programs
But ifBut if P4P is budget neutral P4P is budget neutral Hospitals performing in top decile receive a 2% Hospitals performing in top decile receive a 2%
increment in payments, increment in payments, Hospitals in second decile receive a 1% incrementHospitals in second decile receive a 1% increment Hospitals classified in lowest two deciles are Hospitals classified in lowest two deciles are
liable for a 1 to 2% financial penaltyliable for a 1 to 2% financial penalty
Key MessagesKey Messages
KISS Principle importantKISS Principle important
Key MessagesKey Messages
KISS Principle importantKISS Principle important
Design: Design: Clear performance indicators and targets need to be Clear performance indicators and targets need to be
establishedestablished Do indicators link with outcomes?Do indicators link with outcomes?
Clear methods: the way payment will be tied to resultsClear methods: the way payment will be tied to results If not, signals for behavior change will not be clearIf not, signals for behavior change will not be clear
Key MessagesKey Messages
KISS Principle importantKISS Principle important
Design: Design: Clear performance indicators and targets need to be Clear performance indicators and targets need to be
establishedestablished Do indicators link with outcomes?Do indicators link with outcomes?
Clear methods: the way payment will be tied to resultsClear methods: the way payment will be tied to results If not, signals for behavior change will not be clearIf not, signals for behavior change will not be clear
Administrative:Administrative: Capacity to design, negotiate, monitor and manage contracts Capacity to design, negotiate, monitor and manage contracts
or performance agreementsor performance agreements
Key MessagesKey Messages
KISS Principle importantKISS Principle important
Design: Design: Clear performance indicators and targets need to be Clear performance indicators and targets need to be
establishedestablished Do indicators link with outcomes?Do indicators link with outcomes?
Clear methods: the way payment will be tied to resultsClear methods: the way payment will be tied to results If not, signals for behavior change will not be clearIf not, signals for behavior change will not be clear
Administrative:Administrative: Capacity to design, negotiate, monitor and manage contracts Capacity to design, negotiate, monitor and manage contracts
or performance agreementsor performance agreements
StakeholdersStakeholders Engagement is critical to success to assure that the design of Engagement is critical to success to assure that the design of
the approach will motivate the desired resultsthe approach will motivate the desired results Sufficient buy-in among recipients to generate cooperation and Sufficient buy-in among recipients to generate cooperation and
partnership rather than resistancepartnership rather than resistance..
