Rewards for Specific Domains of Quality

The ultimate goal of pay for performance is to improve quality and patient outcomes. However, current capabilities focus largely on measuring processes of care. Many providers are skeptical that reliable and valid performance measures can be introduced for complex clinical processes. They are also doubtful that incentives can be instituted to reward performance in areas that truly matter—those necessary to improve the health and care of their patients. A major challenge confronting the introduction of pay for performance, therefore, is overcoming the fear that efforts to improve upon one domain of performance may lead to reductions in quality in other domains. Under a new payment mechanism, for example, improved efficiency may greatly benefit the overall quality of the system, yet more important, it may also compromise clinical quality or patient-centered care. Similarly, many purchasers and public officials are concerned that focusing on enhancing clinical quality or patient-centered care will not adequately address concerns about the growing costs of health services or reduce current waste and inefficiencies.

To create new payment incentives that can foster overall quality improvement and better patient outcomes, the committee consolidated the six quality aims of the Quality Chasm report into three domains—clinical quality, patient-centered care, and efficiency. Eventually, if pay for performance is found to have positive effects, other aspects of care should also be measured and rewarded.

Recommendation 4: In designing a pay-for-performance program, the Secretary of DHHS should initially reward health care that is of high clinical quality, patient-centered, and efficient.

Performance Objectives

Two categories of performance benchmarks deserve consideration in designing a payment incentive program: (1) improvement—rewarding all providers who demonstrate significant improvement, and (2) excellence—rewarding those providers who meet or exceed a recognized threshold of desired quality. Current private-sector pay-for-performance programs have reward structures that utilize one or both of these categories.

Recommendation 5: The Secretary of DHHS should design a pay-for-performance program that initially rewards both providers who improve performance significantly and those who achieve high performance.



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