Practical management
Pay for Performance
There is a lot of hype about the new
standards for P4P,
but at its root, it’s just good
practice.
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Pay for performance (P4P) is an emerging
trend that uses economic incentives
to encourage health-care providers to
focus on getting the best outcomes.
Many physicians are concerned about how
this will affect their future and
what they can do about it. Health-care
experts say P4P is unavoidable and,
in the end, is a good thing, so you will
want to get used to the idea. “The
over-riding principles of patient safety,
quality, satisfaction, and
efficiency are driving the move toward
P4P,” says Mary Jean Sage, the
president of The Sage Associates in Pismo
Beach, CA. The Center for
Medicare-Medicaid Services (CMS) has a
demonstration project under way and a
number of larger employer groups and
payers have their own pilot programs.
The objective is to improve care while
reducing inefficiencies that
contribute to a continued rise in
health-care costs. So what’s a physician
to do to get ready for such a program?
Stay in the know “Physicians must
be informed and involved to make a
difference in outcomes,” says Donna
Weinstock, a practice management
consultant in Northbrook, Illinois.
“The goal is promoting quality care and
being compensated for the increased
standard of care.” Learn what you can
about what’s in the pipeline with
P4P and how it is evolving. It will help
you determine what actions you should
take within your own practice.
Avoiding it won’t make it go away.
“Some physicians are protesting the
intrusion on their clinical autonomy,
while others are fretting about the
implications of non-compliant
patients,” says Jack Valancy, a practice
management consultant in Cleveland
Heights, Ohio, “but it’s a good idea,
because it will nudge physicians toward
practicing evidence-based medicine,
which will raise the overall quality of
care.” Busy physicians resist one
more thing expected of them when they
struggle to manage the demands they
already face. Just the same, you
can’t put your head in the sand. According
to Sage, “most programs primarily
measure process—how often doctors provide
patients appropriate treatment or tests
in a number of ‘key’ areas.” These
programs are designed to address quality
issues and improve outcomes,
including preventive care and continuity
of care. “The goal is to add
measures of medical outcomes, such as how
well a physician group manages the
blood-sugar level of diabetics or blood
pressure levels for hypertensive
patients” Sage added. The emerging
programs focus on these three components:
1. Patient satisfaction: What the
patient actually experiences 2. Adoption
of computer technology 3. Effective
clinical treatment and preventive
measures
The biggest stumbling blocks are the
costs to acquire information technology
to get at the data, determining what to
measure, and having realistic
incentives built into the program. Of
these, the technology piece seems to
be the most ominous. Electronic medical
record (EMR) systems, sometimes
referred to as electronic health records
(EHR), are costly to purchase and
integrate into the practice. According to
our experts, implementing an EMR
system is likely to play a role in
financial incentives tied to future P4P
initiatives developed by third-party
payers. “There has to be enough dollar
difference to make it worthwhile,”
says Owen Dahl, a health-care business
consultant in Houston, TX. “A small
percentage increase or return will not
change behavior.” Realistically, if
you haven’t looked at purchasing an EMR
system for your practice, it’s time
to get serious. Not only will this be an
important component of getting ready for
P4P, but such systems add
incredible efficiency to the overall
practice. Yes, it’s costly to implement
an EMR, but most practices recoup the
costs within 18 months with reduction
in staffing and time savings. Physicians
report being able to see more
patients with better documentation after
implementing an EMR system—and
physicians and their clinical staff find
they work in “real time” which
often means getting out of the office
earlier at the end of the day. The
on-call doctor can access patient records
off-site. This helps him make the
best decisions for the patient after
hours, which can directly affect the
patient’s clinical outcome.
Start making moves As for young
physicians who are just getting started,
it’s hard to say how much P4P will
affect them. “They should have the latest
and greatest knowledge in place”
says Dahl. If they join a practice, they
can play an important role in moving the
practice to a higher performance
level and influence change, whereas the
old guard are more likely to want to
keep that status quo. “Don’t
flatly discount the idea of P4P if asked to
participate,” added Sage. Find out
what’s involved—the challenges and the
potential benefits. The more you know,
the better off you will be when it’s
time to make decisions for your practice.
“At this point, participation in
P4P programs is often voluntary, so each
practice needs to assess how
feasible it is to participate” says
Sage. “Who will measure what and how
will it affect costs and
revenue—and what will the future hold if you don’t
participate?” One of the primary
factors in implementing clinical measures
is physician agreement on how you will
measure quality. “Do you know,
understand, and agree?” asks Dahl.
Measure what you can measure easily that
can affect change without turning your
practice upside down or causing you
to spend endless hours and a great deal
of money administrating it. It
doesn’t have to be complicated.
Patient satisfaction is a good starting
point. It’s already being measured
by the payers, so do your own survey and
respond to the results. Tap into your
scheduling system for starters. Start
with access. How long does a new patient
have to wait for an appointment and
is it reasonable? Are you meeting
existing demand? Sometimes it’s a matter
of tweaking the scheduling system. Find
out how responsive you are to phone
calls by documenting when the call came
in and when disposition was
complete. If you monitor this for a few
days it can be very telling. It may
mean it’s time to set a standard
for timely response for clinical calls and
improve efficiency so the standard can be
met. Of course, you will need to
monitor your progress by spot checking
performance from time to time. Most
experts agree that when it comes to
conducting patient satisfaction surveys,
it’s not in your best interest to
do a home-grown survey. Hire a health-care
marketing consultant. The survey is
useless if it is not a valid sampling or
if the survey instrument is not designed
to objectively measure the
findings. Besides, your management team
is unlikely to have time to dedicate
to such an ambitious project. The power
of the survey is your ability to act
on the results—tout what you do
well and take corrective action where your
marks indicate performance is weak.
Not everything is costly It may seem
overwhelming and costly to implement an
internal program, but it’s not
necessarily so. As far as clinical measures,
tackle something where the information is
easy to get and to which you can
respond effectively. For example, flu
shots on your senior citizens. Most
practice management systems can pull the
data to let you notify patients to
get their flu shots and you can improve
access by conducting regular flu
shot clinics during the season.
Electronic communication allows you to
inform your patients when it’s time
for an annual examination or for
diagnostic follow-up on certain
conditions. The good news is these one-way
communication systems are very affordable
and they can access data directly
from your practice management system,
saving you endless hours. It’s time to
move beyond the basic appointment
reminder system. A powerful Web site is
one of the best and least costly
investments you can make to get a program
rolling. When a Web site is properly
designed, it becomes an interactive
tool to share information with patients
and keep them educated. You can
establish links to send patients to sites
that provide information about
their condition and access to support
groups you choose to recommend. You
can even develop an e-newsletter to share
clinical information and improve
compliance. For example, in the late
spring you may want to remind patients
it’s time to get out the sunscreen.
In the summer, remind parents to
schedule the exams for their children and
get them immunized before school
starts, and in the fall let patients know
when you will be having a flu shot
clinic. Add to this an e-mail reminder
system for annual paps, mammograms,
diabetic eye exams, or whatever applies
to your specialty. These reminders
can be reinforced with a “message
on hold” system for patients who call into
the office and are in the queue. With a
little effort and ingenuity, you
will be on your way to improving
compliance and, ultimately, outcomes. In
reality, everyone is paid for
performance. The more efficient any business
is, the more profitable it will be. Not
only will you improve the practice’s
financial margins by implementing a
formal P4P program, it is expected that
third-party payers will provide as much
as a 10-percent differential
reimbursement for the top performing
practices. When this occurs, group
practices are likely to establish
compensation programs that reward
individual physicians in the same manner.
There are lots of reasons to get
on board with plans to implement programs
that measure quality and provide
intervention in areas where performance
is weak. The ultimate gain with P4P
is to improve the health of the patients.
The future of P4P Our experts agree that
P4P is here to stay. “I expect
Medicare’s P4P system will be
revised before it’s adopted on a broader scale
and will be continuously refined as new
evidence emerges” says Valancy.
Physicians should be willing to think
differently. “You may need to shift
your way of practicing medicine and
cultivate a new mind-set and skill set
to track illnesses, develop reminder
systems to improve compliance, and
distribute patient education
materials,” Sage says. “When a program is
properly administered, it becomes a
win/win situation for both the physician
and the patient,” adds Weinstock.
If you are part of a bigger practice you
may already see P4P initiatives emerging
or they are likely to be a factor
in your future
compensation—that’s called accountability! If you
are a solo
physician or part of a small practice,
don’t be intimidated by what you
hear. Gather information and take small
steps to get yourself started with
implementing a program that makes sense
for you—something you can commit to
that will measure outcomes and customer
service. In the end, the emergence
of P4P may be an opportunity for
physicians to reevaluate their own
practices. Define who you are and what
you are all about. What is your
practice’s philosophy and purpose?
Make a commitment to take concrete,
measurable steps to be sure you are
living your mission.
Judy Capko is a health-care consultant
with more than 20 years experience and the author of
“Secrets of the Best Run Practice.” Her focus is
practice operations, staffing, finance, and marketing. Judy is
based in Thousand Oaks, CA and can be reached at judy@capko.com
or through www.capko.com
