Question

Summarize of paper that include what is pay for performance how could it stimulate or encourage the EMR adoption? what are the advantage and the limitation of cost-benefit analysis from the it adoption decision? supposed to practice had decided not to adopt the EMR what would have been the cost of such decision and what Milestone should be achieved in the term of it Reading Readiness before a group of practice decide to implant the EMR or could there be less and intensive and indifference set off challenge form for smaller practice to the take of the HMIS projects such as the EMR implementation that largest Care Health Services organization such as the multi provider Health maintenance organization if so what is the difference in the term of the incentive why and why not

Answer 1

Pay for Perfomance (P4P)

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance.

Measures adopted by medical groups include speeding up adoption of information technology such as electronic medical records, more closely tracking the improvement of physician performance and sharpening institutional focus on quality, Pay-for-performance programs in health care have grown rapidly in recent years as a way to improve the quality of care delivered by doctors, hospitals and other health care providers. Despite the rapid adoption of these programs, there is little research about how well they work and what types of strategies work best.

Under the program, physician groups receive financial bonuses if they meet certain performance guidelines such as increasing the number of patients with diabetes who receive recommended blood tests. Other performance measures include improving patient experience with getting care and adopting health information technology capabilities.

Between 2003 and 2007, the participating health plans paid $203 million in incentives to participating physician groups. Although there is some concern that pay-for-performance might cause physicians to drop patients who decline to follow recommendations, few reports of such events were received. More than two-thirds of the medical groups reported that the pay-for-performance program resulted in more positives than negatives. Most physician organizations said they collected more bonus payments than they had spent to comply with the program, although six said it was barely enough to cover their costs. Twenty of the medical groups surveyed said the program had affected the behavior of their individual physicians, prompting them to embrace quality efforts such as performing more-intensive outreach to patients.

We all know that our healthcare system is very expensive and massive efforts are underway to implement reforms. The reforms come in many different areas, with differing levels of impact as there is no “silver bullet” that will fix the system. One of the major reform undertakings has to do with how providers and hospitals are paid.

Currently we operate primarily in a “Fee for Service” (FFS) environment. Under FFS, providers are paid for performing a specific service: an operation, procedure, consult, etc. One of the problems with FFS is that it assumes that providing a service is synonymous with a patient achieving a certain, generally positive, outcome (remission from disease, for example). That is not always the case. Alternatively, if you were to ask a patient what he/she would like to “purchase” when seeing a provider, they would reply with something like “I would like to get my condition under control”, or “I would like to be cured of this disease”, i.e. the patient would like to “purchase” an “outcome” or “result”.

The concept of “purchasing” an “outcome” has been around for a while and is known by various names: Pay for Performance, Outcomes Based Payments, Value Based Purchasing and Accountable Care are a few. Over time, the industry will standardize on a single term, but in this article we use the term Pay for Performance (P4P). There are several important things to know about P4P:

• Essentially, P4P uses financial bonuses to encourage physicians to meet standardized performance quality measures and to boost positive clinical outcomes and patient satisfaction (just as an aside, in the US today, 75% of all companies associate at least part of an employee’s pay to measures of performance).
• It does not apply to treating an individual patient. Rather it applies to a group of patients in a panel, where outcomes can be statistically predicted with accuracy.
• It cannot apply to all conditions and diseases. It only applies to patient panels with specific conditions. These conditions are those where the outcomes can be predicted with statistical accuracy. For example, starting October 1, 2012, hospitals will be reimbursed differently for three conditions: heart attacks, heart failure and pneumonia. The payment rate allows only a certain amount of readmissions. If a hospital’s readmission rate is considered to be excessive, they will be subject to rate reductions.

We are not trying to argue the merits of P4P. However, it will become, in one shape or form, part of the payment system in the future. In addition to the Medicare announcement mentioned above, United Healthcare recently announced that they will be paying for some oncology services in this manner. Most major payers have some type of P4P program in place or are developing one.

As mentioned above, P4P relies on a lot of data, from a lot of patients. You can’t P4P unless you can measure performance. You certainly cannot implement a P4P program with a physician that is using paper charts. The data that is resident in a physician’s EHR will be instrumental in determining what actual performance or outcomes are.

As a side note to the above, the data must be available in a standardized electronic format for it to be evaluated.

A shift to accepted evidence-based standards of care will be required. For certain conditions, physicians will be asked to use certain clinical policies and procedures. EHRs will be used to document that these standards have been adhered to.

Many P4P programs will involve the concept of the Patient Centered Medical Home. This does not just apply to primary care physicians. Part of PCMH involves identifying gaps in care – as an example, making sure every patient over 50 receives a colonoscopy at the appropriate intervals. These gaps in care can only be identified by and addressed using the data in an EHR. The EHR cannot only be used to identify gaps in care, but also any type of medical data point, i.e. patients with certain lab results, patients on certain medications, etc. By rapidly identifying patients with certain characteristics, physicians can quickly target appropriate care.

Meaningful Use is just the first stop in the long journey of utilizing EHRs in the transformation of the healthcare system as we know it. EHRs will be used not only to improve clinical outcomes, increase practice efficiency, but will also be an integral part of the payment systems of the future.

PROS AND CONS OF PAY-FOR-PERFORMANCE IN HEALTH CARE

PROS	CONS
Can align the interests of the payers and providers to deliver higher-quality care	Difficult to design programs to encourage intended behavior while preventing unintended behavior such as cheating and avoidance of high-risk patients
Performance bonuses can be invested in efforts to further improve quality	May undermine health care professionals intrinsic motivation to provide high-quality care
Can focus providers attention on meeting specific performance targets	May fail to motivate system-level changes to improve populatin health