Key Elements: Aligning Financial and Other Incentives

To provide safe, effective and affordable health care.

Principles for Pay-for-Performance Programs (specifically, Program Rewards):

• Programs must be based on rewards and not on penalties.
  
• Program incentives must be sufficient in scope to cover any additional work and practice expense incurred by physicians as a result of program participation.
  
• Programs must offer financial support to physician practices that implement IT systems or software that interact with aspects of the PFP program.
  
• Programs must finance bonus payments based on specified performance measures with supplemental funds.
  
• Programs must reward all physicians who actively participate in the program and who achieve pre-specified absolute program goals or demonstrate pre-specified relative improvement toward program goals.
  
• Programs must not reward physicians based on ranking compared with other physicians in the program.
  
• Programs must provide to all eligible physicians and practices a complete explanation of all program facets, to include the methods and performance measures used to determine incentive eligibility and incentive amounts, prior to program implementation.
  
• Programs must not financially penalize physicians based on factors outside of the physician’s control.
  
• Programs utilizing bonus payments must be designed to protect patient access and must not financially disadvantage physicians who serve minority or uninsured patients.

Rewards physicians for adopting health IT or EHRs.

• Assess the use of evidence-based standards of care, maintenance of patient registries for the purpose of identifying and following-up with at-risk patients and provision of educational resources to patients.
  
• Assess whether practices use electronic systems to maintain patient records, provide decision support, enter orders for prescriptions and lab tests and provide patient reminders.
  
• Assess whether a practice’s electronic systems interconnect and whether they are interoperable with other systems, whether they use nationally accepted medical code sets and whether they can automatically send, receive and integrate data such as lab results and medical histories from other organizations’ systems.

To ensure that members receive important preventive services, create performance-based reimbursement opportunities for PCPs and provide PCPs with actionable patient data to enable improvements.

Program Elements:

• Provides annual reports to physicians on five different measures, a list of patients yet to receive preventative care for those measures, educational tools and materials and payments based on performance.
  
• In 2003, BCBSMA expanded its pay-for-performance initiative to engage groups and specialists in quality improvement efforts through the Group Performance Incentive Program.
  
• BCBSMA will leverage these programs’ resources in 2004 to encourage physicians to invest in and use electronic technologies for disease management, decision support and electronic prescribing. BCBSMA expects this to have far-reaching effects in the delivery of quality care to their members and all the citizens of Massachusetts.

To assist states in developing Medicaid provider incentive programs.

The seven states and their agendas include:

Arizona is partnering with its managed care organizations to develop a statewide provider-level incentive program. The state is concurrently working on pay-for-performance arrangements targeting hospitals, nursing homes, home health agencies, and health plans.

Connecticut seeks to institutionalize incentives for care coordination, preventive care, and other activities for children enrolled in its Medicaid program under a pay-for-performance program.

Idaho is incorporating pay-for-performance into its primary care case management Chronic Disease Management Program. The initial pilot focuses on diabetes, using six evidence-based quality indicators. Idaho is in the process of adding depression and hypertension diagnoses to the program. Providers will receive a $50 incentive payment for every person with diabetes who is enrolled, and $10 for each of the selected indicators that have been performed or competed.

Massachusetts seeks to implement pay-for-performance within its primary care case management program. The state’s goals for provider-level pay-for-performance include:

• Establishing a framework for MassHealth pay-for-performance activities that focuses on improving the quality of care delivered to members across care delivery settings.
• Using a phased approach to implementing pay-for-performance in MassHealth.

Missouri proposes to implement financial incentives for providers who actively participate in its disease management program.

Ohio Medicaid is planning to coordinate provider pay-for-performance into a statewide managed care program. The state is currently identifying performance indicators for preventive care and for the most costly and prevalent chronic diseases.

West Virginia is developing a provider-level “pay-for-play” program to go hand-in-hand with its Medicaid Redesign goals. In the initial year, providers will be reimbursed for time spent with patients explaining the state’s member agreement and establishing a self management plan. In the second year of the program, provider incentives will be tied to performance measures

Hospital Quality Initiative

Premier Hospital Quality Incentive Demonstration

Performance Based Payments for Physician Groups Demonstration

Medicare Chronic Care Improvement Program

Medicare Care Management Performance Demonstration

Standards and Performance Measures Development

To determine the impact of offering incentive payments to different providers for improving the quality of care rendered to Medicare beneficiaries when such quality of care results in reduced need for additional services and, consequently, reduces cost.

To determine the impact of offering incentive payments to different providers for improving the quality of care rendered to Medicare beneficiaries when such quality of care results in reduced need for additional services and, consequently, reduces cost.

This statewide collaboration is designed to create the business case for quality at the physician group level. The goal is to reward physician groups for performance in clinical care and patient experience by providing a clear set of health plan expectations, use of common metrics, and public reporting. Six health plans participate

IHA’s principles of Pay for Performance are (1) common performance measures for physician groups, developed collaboratively by health plan and physician group medical directors, researchers, and other industry experts; and (2) significant health plan financial payments based on that performance, with each plan independently deciding the source, amount, and payment method for its incentive program.

To improve the standard of care and control costs through financial incentives to doctors and their patients for incorporating evidence-based medicine and information therapy methods.

Designed to “bolt-on” to existing health plans to improve the standard of care and control healthcare costs. MedEncentive accomplishes quality improvement and cost containment by dispensing evidence-based medicine (EBM) treatment guidelines and information therapy (Ix) to physicians and their patients through MedEncentive’s proprietary Internet Website applications

To financially incentive physicians to provide a higher quality of care.

Pay-for-performance measurement criteria:

• Measures must be evidence-based, to the extent possible, broadly understood, and accepted
  
• Providers and plans must be able to improve quality by using the measures; otherwise care may be improved for only a few beneficiaries
  
• Incentives should not discourage providers from taking riskier or more complex patients
  
• Information to measure the quality of a plan or provider should be collected in a standardized format without excessive burden on the parties involved.
  
• Establish a process for continual evolution of measures.

Principles for physician payment:

• Reward providers based on both improving care and exceeding certain benchmarks.
  
• Medicare should fund the program by setting aside a small share of payments in a budget neutral approach.
  
• Distribute all payments that are set aside for quality to providers achieving the quality criteria.
  

eValue8:
Seeks to provide standardized information in order to improve their management, administration and/or delivery of health care services.

NBCH:
Seeks to accelerate the nation’s progress towards safe, efficient, high-quality health care and the improved health status of the American population.

NBCH Principles:

• Value-based health care purchasing
  
• Measuring the comparative quality and efficiency of hospitals, physicians, and health plans in the community to identify the best value
  
• Creating incentives to provide higher-value care through integrated delivery systems and continuous quality improvement
  
• Improving the overall health of the community

To improve health care quality, lower administrative burden, enhance transparency, and support a patient-centered, consumer driven environment.

Tenets of Prometheus Payment:

• Providers have the opportunity to negotiate meaningfully their payment amounts in accordance with the Evidence-Based Case Rate.
  
• Mechanisms of payment and systems of reporting are transparent and public.
  Providers have the option to configure themselves in whatever aggregations they choose.
  
• The implementation of PROMETHEUS explicitly seeks to lower administrative burden wherever possible.
  
• Providers measured for efficiency will have information about other providers in order to facilitate effective referral choices.
  
• Providers have the opportunity to speak to scorecard issues (e.g., data, findings before they are made public.

A solution to help purchasers and payers obtain more value from their inpatient care in collaboration with their hospital community by
creating incentives and rewards for high-value care.

Provides a foundation for hospitals to become national leaders in the movement to improve quality health care and provide exceptional value for the communities they serve.

The Leapfrog Group principles:

• Reduce preventable medical mistakes and improve the quality and affordability of health care.
  
• Encourage health providers to publicly report their quality and outcomes so that consumers and purchasing organizations can make informed health care choices.
  
• Reward doctors and hospitals for improving the quality, safety and affordability of health care.
  
• Help consumers reap the benefits of making smart health care decisions.

To improve the quality of clinical care by supporting physicians in their practice of evidence-based and efficient health care delivery.