Rewarding Provider Performance Aligning Incentives in Medicare (2007) / Chapter Skim
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4 Distribution of Rewards
4 Distribution of Rewards
Pages 80-101
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From page 80... ...
The health care delivery system has evolved over time with better understanding of diseases and the human body and the development of new technologies and procedures. Provision of medical care is significantly different from what it was 40 years ago when Medicare began; yet the fee-forservice payment system has changed little, except for the replacement of cost-based prospective payments.
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From page 81... ...
For example, many purchasers are concerned that performance measures emphasizing enhanced clinical quality will lead to an unrestrained growth in costs and a minimal effort to reduce current waste and inefficiencies. Any pay-for-performance program must address these concerns by clarifying the goals and objectives of new payment mechanisms.
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From page 82... ...
Domain-Based Rewards There are numerous ways a reward pool could be divided among the three domains of clinical quality, patient-centeredness, and efficiency. The following discussion illustrates simplified versions of the options the committee considered.
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From page 83... ...
Practical considerations -- namely, that there are few well-developed measures available for patient-centeredness and efficiency (see the discussion below) -- led the committee to conclude that, initially at least, most of the reward pool should be allocated to incentives for improved clinical quality, where applicable.
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From page 84... ...
For example, if the baseline performance measure for hospital A were 80 percent, its failure rate would be 20 percent. If 1 year later hospital A's performance had improved by 4 percent to 84 percent, the reduction in its failure rate would be 20 percent.
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From page 85... ...
. WHAT MEASURES SHOULD BE USED FOR REWARD-BASED PAYMENTS Identifying Measure Sets for Assessing Performance How payments are distributed within each of the three domains depends in part on the measures employed.
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From page 86... ...
Existing measure sets are organized largely by care setting. Building on the starter set of measures presented in the Performance Measurement report, the committee believes the measures presented in Table 4-1 should be used in the short term for a pay-for-performance program with the exception of the Minimum Data Set, which should not be used in pay for performance to provide incentives for skilled nursing facilities (see Chapter 5)
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From page 87... ...
, quality measures addressing overuse or misuse (2) Ambulatory Care Survey CAHPSb Clinician and Group Survey: getting care quickly, getting needed care, how well providers communicate, health promotion and education, shared decision making, knowledge of medical history, how well office staff communicate Acute Care Hospital Quality Alliance (22)
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From page 88... ...
Data systems are increasingly being designed with the capacity to collect more "meaningful" data electronically; this capability will be greatly accelerated by the adoption of health information technologies (see Chapter 5)
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From page 89... ...
The Performance Measurement report also proposed that research be carried out to determine how each measure 2Data were derived from the Medicare 5 percent sample. Payment figures represent total physician fee schedule payments in the groups of diabetes, chronic heart failure, and coronary artery disease.
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From page 90... ...
This approach might involve rewarding providers that have in place such structures as clinical care teams, care coordinators, and health information technology systems that are thought to improve the overall safety, timeliness, and efficiency of care. Some structural measures related to information technology, such as computerized provider order entry, intensive care unit intensivists, and evidence-based hospital referrals, are included in the starter set identified in the Performance Measurement report.
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From page 91... ...
For example, if the distribution of scores were low, providers in the 90th percentile might actually be delivering good care only 40 percent of the time, as defined by performance measures. The high level of uncertainty as to the amount of the rewards providers might receive could also be a disadvantage of this method because it might make providers hesitant to invest in quality improvement.
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From page 92... ...
92 REWARDING PROVIDER PERFORMANCE constantly reviewed and set higher as long as average performance improves and higher levels of achievement are possible. Graduated or Fixed Rewards Distribution of rewards could be either graduated or fixed.
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From page 93... ...
DISTRIBUTION OF REWARDS 93 Baseline $30 $30 No rewards Eligible for rewards 0% 50% 65% 95% 100% FIGURE 4-2 Eligibility for fixed rewards based on performance improvement. If fixed rewards were provided for performance, Bloomfield Home would receive $50 whether its performance were 85 or 99 percent.
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From page 94... ...
Certain procedures and types of care are provided in a variety of settings. For example, minor surgery might be provided in outpatient hospital departments, ambulatory surgical centers, or physician offices; postacute care might be provided by a skilled nursing facility unit in an acute care hospital, a free-standing skilled nursing facility, or a home health agency.
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From page 95... ...
Models for Distribution As discussed previously, rewards should be focused on the three domains of performance by setting of care and by condition. The next question for consideration is how the reward pools for improvement and excellence should be allocated among these domains.
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From page 96... ...
Option 2 An alternative system might require that a minimum threshold level of excellence be reached in one, several, or all domains for a provider to receive any points in the other domains. For example, a provider might have to score at or above the 50th percentile on clinical quality to receive points for efficiency.
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From page 97... ...
It assumes that rewards would be allocated based on (1) provider type (e.g., hospital, physician, home health agency)
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From page 98... ...
Composite Score For his patients with coronary artery disease, Dr. Roller is evaluated by Medicare on how well he performs on the following clinical quality measures: drug therapy for lowering LDL cholesterol, beta-blocker treat ment after heart attack, and persistent beta-blocker treatment following myocardial infarction.
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From page 99... ...
Roller's points for improvement and excellence are both 0.10. His care of patients with coronary artery disease receives a total of 0.20 points.
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From page 100... ...
In addition, it is worth noting that payment incentives will be accompanied by public dissemination of performance data, which may prove to be an even more powerful motivator for improving overall quality. Pay for performance uses incentives to encourage providers to improve.
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From page 101... ...
. · The role of health information technology: how new technologies can influence the implementation of pay for performance.
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