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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Pay for Confusion: Current State of P4P

Confusion (kən-fyūzhən) n.
  1. Impaired orientation with respect to time, place, or person;
  2. The act of confusing or the state of being confused; an instance of being confused
  3. A disturbed mental state.

There have been several recent articles over the past week regarding Pay for Performance (P4P). I have previously been critical of the current incantation of P4P as it is more reflective of “Pay for Process”. While many programs fall short of tracking measures that matter, I am pleased to see that they are tracking, and more importantly reporting, something. Forward progress is forward progress!

Modern Healthcare recently had an article which highlighted some recent studies regarding the plethora of new programs being introduced nationwide. Since 2003, there has been a steady annual increase in P4P programs growing from 39 to 84 to 107 to approximately 148 in 2007. A noted challenge with this exponential growth is the to determine exactly what all these programs are tracking. Turns out that many use standard measures from AQA, NCQA, NQF, the Joint Commission, and groups like Leapfrog. However, there is quite a bit of homebrew in there as well, which I support in the short term, but that will need to be codified at some point into measures that matter (That is a catchy phrase that someone should pick up on).

A couple of relevant quotes:

  • Price Waterhouse Cooper Report: “Pay-for-performance programs can be an important tool to link payment to quality, but the wide variation in program structures, performance metrics and rewards structures mutes their potential impact.”
  • Susan DelBanco, CEO LeapFrog Group: “The P4P and Consumer Incentive Survey demonstrates clear evolution in P4P programs. They are assessing hospital and physician quality more broadly and beginning to emphasize measures of efficiency. The programs also directly lead to greater availability of publicly reported information that is useful to employers and consumers.”
  • Francois de Brantes, National Coordinator for the Bridges to Excellence physician-reward program: ”Most of the employers and the plans we work with are increasingly cognizant of the fact that this [variability of P4P measures] just creates a lot of noise, and that we need to strengthen the signal by having very clear standardized measures used by multiple plans and employers in a single community.”

So I am stoked to see the progress, but concerned about the confusion created with all the current programs. The auditory dissonance in the experimentation phase is more than appropriate, and with appropriate encouragement and steerage the current cacophony can become a high performance chorus singing a perfectly-pitched, unified aria of quality. I think what can get us there is the thought leader groups to continue to press forward with scientific methodology that can be widely applied to get us to some reasonable measures that really matter.

I hope to see ongoing, and continued physician involvement, in the shaping, development, and promotion of these programs as part of a wider movement toward a more transparent health care delivery system. Physicians, like no other players in the system, have a vested interest in differentiating themselves based on the objective outcomes of their patients. I would like to see them turn this P4P movement into a weapon of promotion and differentiation for them versus the tool of the adversary against them. And to be fair, health plans and other types of health providers need to be put to held to the same transparency fire as well.

So while the current state remains one of confusion, I believe the “din and roar” is from the buzz of a burgeoning healthcare market getting in tune with the new healthcare harmonics

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