Healthy Living Patient-Centered Life-Cycle (Pclc) Value Chain--Process Reform: Pay For Value

Continuing the serial on the PCLC Value Chain strategy [click hither for the outset postal service inward the series], this postal service focuses on a 3rd physical care for inward demand of reform: The transformation from "pay for performance" to a "pay for value" model that rewards providers who deliver high-value to patients/consumers. Being a complex too controversial issue, this postal service is lengthy, but hopefully insightful.

Defining Pay for Performance

Today's Pay-for-Performance (P4P) model uses "quality" measures (metrics)--devised past times insurers, authorities too large healthcare institutions--to gauge the performance of providers (hospitals too clinicians) too pay them based on their performance. In the P4P process, monetary rewards are given to providers who follow specific evidence-based guidelines for especial types of patients and, for roughly conditions, who laissez passer on for certain results inward patient wellness too well-being. And recently, the Centers for Medicare too Medicaid Services (CMS) decided to add together a "stick" to the P4P "carrot," past times announcing that they volition cease paying for aid made necessary past times "preventable complications;" that is, they won't pay for for certain weather condition caused past times medical errors or improper care--conditions that could possess got reasonably been avoided.

Thus, reforming healthcare via P4P "…rests on the next 3 principles: payers [insurers too CMS] should pay to a greater extent than for the handling of weather condition that require to a greater extent than resources too that the provider could non reasonably possess got prevented; they should pay to a greater extent than when evidence-based or consensus-based best practices are followed; too they should pay less or non at all for low-quality care. Naturally, the terminal volition hold upward the most controversial."[1]

While such an incentive model may touching clinician conduct [2][3], too although the number of P4P programs is growing, critics say that they increment providers' administrative burden piece giving no clear evidence coin volition hold upward saved or character volition hold upward improved.[3a] Furthermore, using compliance to evidence-based guidelines equally the mensurate of performance tin hold upward problematic for numerous reasons.[4][5]
These issues too others pose important challenges to whatever P4P program.

P4P Challenges

P4P programs must bargain alongside the next challenges:

• A provider's practise may hold upward also minor to let valid analysis of the performance data.
• Patient population differences--in terms of wellness status, insurance coverage, etc.--may hateful that a specific practise guideline may piece of work good for for certain patients inward for certain situations, but non piece of work for others.
• Even though providers may adhere to practise guidelines tied to P4P, they may non comply alongside guidelines for which at that topographic point is no performance assessment too fiscal incentive.
• Many specialties lack evidence-based guidelines, too the guidelines that be may non hold upward valid.
• Performance metrics must hold upward adequately "risk-adjusted" for patients alongside hard to care for problems. These risk-adjustments alter the criteria for determining "successful" aid past times accounting for differences inward the severity of patients' weather condition treated past times different providers, thereby enabling fair comparisons. It tin hold upward really difficult, however, to found valid are risk-adjustment equations.
• When a guideline is non clinically appropriate for a especial patient, a provider should non hold upward penalized for deviating from it alongside minimal, but appropriate, documentation.
• P4P programs may terminate upward costing the scheme to a greater extent than inward the long run.
• If providers chase different P4P criteria developed past times different payers, it tin atomic number 82 to duplication of services too unnecessary testing.
• Different insurer-based P4P programs oft mensurate performance differently, which results inward unnecessary administrative burdens, equally good equally failing to suit for differences inward patients' conditions, economic science too demographics.[5a]
• Since character metrics are largely arbitrary, different healthcare plans tend to possess got different performance indicators for the same disease, which convolutes the process.
• P4P could just redirect coin toward wealthier areas where patients are to a greater extent than probable to follow doctors' orders.
• Patient satisfaction surveys tin hold upward unreliable.
• When a patient is treated past times multiple clinicians, it tin hold upward unclear who is responsible if a recommended guideline isn't followed.
• A patient's mightiness too willingness to adhere to self-maintenance instructions oft touching outcomes, thus impacts provider performance measures.

One way P4P programs endeavor to bargain alongside such challenges is past times establishing useful performance measuring standards.

Performance Measurement Standards

At to the lowest degree 3 standards are related to measuring clinician too infirmary performance:

1. Process compliance standards
2. Care outcome standards
3. Care value standards.

Process Compliance Standards

Process compliance standards mensurate the "quality" of providers' performance based on whether they follow recommended guidelines reflecting preferred aid processes. For example, typical P4P programs vantage providers who perform for certain predefined procedures (processes), such equally doing a Hemoglobin A1c evidence a for certain number of times each yr for patients alongside diabetes. These standards mensurate the bird of compliance to such established procedures.

Some of the problems alongside P4P are exemplified past times inquiry showing that next recommended procedural guidelines for hospitalized patients alongside midpoint attacks--e.g., give patients aspirin too beta blockers at admission too discharge--doesn't hateful improve outcomes equally measured past times 30-day mortality rates.[6] So, later xxx days of an attack, the inquiry shows that the wellness status of a patient alongside actuate myocardial infarction is influenced alone slightly past times whether or non his/her provider followed the guidelines. This is because outcomes inquiry is soundless an baby science, which makes P4P premature, at best. In this case, too inward many others, measures of performance are also unsmooth (i.e., express whether the patient died inside xxx days, but ignores what happens later that time) too also narrow (i.e., aspirin, beta blockers too a few or recommended interventions are inadequate to address all of a patient's needs too problems). So, it appears that aid character is non necessarily related to guideline compliance.

Let's examine this number a fleck to a greater extent than deeply. Adhering to existing physical care for guidelines are, no doubt, helpful for many patients. But numerous other things non appearing inward a physical care for guideline, too thus non used to mensurate the character of care, may hold upward equally of import (and mayhap to a greater extent than important) to improving a patient's wellness too well-being.

For example, of import processes lacking inward today's P4P guidelines, too non beingness considered equally character metrics, include:

• Educating a patient suffering from congestive midpoint failure almost the pros too cons of a midpoint operation
• Counseling too coaching the patient to brand critical lifestyle changes (e.g., proficient eating too exercise) too to contend stress to a greater extent than effectively
• Implementing cost-effective complementary too alternative interventions
• Using computerized diagnostic aids, clinical pathways, continuity of aid records, too electronic medical/health records.

Other of import processes affecting aid character that P4P programs neglect to mensurate include:

• How good a patient's innovation of aid maps to his/her primary diagnosis too comorbidities (the presence of 1 or to a greater extent than disorders/diseases that co-exist alongside a patient's primary disorder/disease)
• Whether a innovation of aid is based on a full general guideline, or whether it is personalized, i.e., tailored to each patient's unique province of affairs past times taking into concern human relationship patient-specific biomedical, psychological, genetic, cultural, too historical factors, equally good equally one's personal preferences
• How good aid is coordinated amidst a patient's providers later discharge from the hospital
• The character of aid delivered inward both inpatient too outpatient settings (e.g., whether at that topographic point were errors, omissions, infections, etc.)
• The patient's mightiness too willingness to comply alongside self-management aid plans to forestall complications or worsening a condition
• The appropriateness of the self-management aid plans, equally good equally patient instruction too compliance counseling/coaching.

Care Outcomes Standards

Unlike physical care for compliance standards, aid outcomes standards do non focus on whether specific procedures were followed. Instead, they mensurate the effectiveness of whatever treatments were delivered, too whether clinical goals are achieved for patients alongside especial conditions. For example, a aid outcome measure for diabetics is blood glucose command defined equally a Hemoglobin A1c evidence target finish of less than 7.0%. This way aid outcomes information should mensurate to a greater extent than than mortality rates (patient deaths); they should also mensurate a patient's physical too psychological signs too symptoms--including patient complaints, clinician observations, vital signs, lab evidence results, imaging studies, too character of life (such equally mental health, mobility, social functioning, role limitations, vitality, etc.).

Interpreting aid outcomes information ought to accept into concern human relationship factors that may influence the aid results, such as:

• Comorbidities too their termination on the patient
• Allergies too other things that tin crusade adverse reactions/side-effects
• Environment weather condition (at home, inward the workplace, etc.)
• Treatment history
• Family history
• Genetic markers
• Patient's attitudes too preferences
• Patient's emotional state
• Patient's psychosocial province of affairs (e.g., bird of solid unit of measurement support).

Understanding how to work aid outcomes to mensurate quality, therefore, is a complex physical care for that requires a wealth of various wellness data. Unfortunately, existing P4P programs do non work comprehensive aid outcomes to assess the character of care. Instead of obtaining too analyzing detailed lots of clinical information (signs too symptoms), they typically rely on insurance claims (administrative) data.

Claims information furnish roughly useful measures of quality, including mortality rates, complications; too claims information furnish useful information almost cost. These data, however, furnish grossly inadequate metrics for improving aid character too efficiency. This is because claims information do non include information necessary to determine, for example, how much a patient's signs too symptoms improved later treatment, if errors were made, if lower cost treatments of equal or greater effectiveness could possess got been used, if the patient was educated adequately inward self-care too complied alongside the prescribed innovation of care, too if coexisting weather condition affected results. Without such aid outcomes data, it isn't possible to evaluate a provider's performance accurately nor gain the noesis needed to improve healthcare effectiveness too efficiency. So, instead of using claims information lone to mensurate aid outcomes, they should hold upward augmented alongside detailed clinical data.
Measuring physical care for compliance, too balancing clinical too claims outcomes information are essential to assessing aid quality, but rewarding cost-effectiveness require aid value standards.

Care Value Standards

In contrast to aid physical care for too outcomes standards, aid value standards combine physical care for too outcome character metrics alongside economical metrics to mensurate cost-effectiveness, which defines the value of care.

If our healthcare scheme was rational too guided past times wisdom, a pinnacle priority of healthcare professionals too patients/consumers would hold upward to maximize aid character too efficiency (i.e., value) by:

• Gaining valid noesis almost salubrious living, the causes too diagnosis of physical too mental wellness problems, too the treatments delivering the best results most cost-effectively to each patient.
• Understanding how to work this noesis to maximize value to the patient/consumer past times increasing aid effectiveness too efficiency, equally good equally improving prevention too self-maintenance of chronic diseases.
• Continuously evolving this noesis too using it to improve aid character too lower costs continually.

For important improvement inward healthcare delivery, useful too reliable aid value standards must hold upward established for every wellness conduct a opportunity factor, illness/condition, too healthcare discipline/field; too these standards must hold upward used to mensurate too vantage high-value performance. Unfortunately, today's P4P programs neglect to do this since, inward part, measuring aid character is so difficult.

Pitfalls of Care Quality Measurement

Following are potential pitfalls of aid character measurement:

• Today's diagnostic systems oft neglect to betoken to the highest character handling options, which way nosotros oft don't know the what aid interventions are probable to create the best results.[7]
• Few guideline standards are specific plenty to concern human relationship for private differences inward patient alongside the same diagnosis. For example, a recent written report found that a moderately high total cholesterol bird is associated alongside higher survival inward for certain patients alongside midpoint failure.[8] Such specificity is needed for high character personalized care.
• Constantly evaluating too revising evidence-based guidelines based on novel noesis is really difficult. But if they do non continually evolve, the guidelines do non promote character since they are just "a tape of the past, too petty more-they should possess got an expiration date."[9]
• According to HHS Secretary Mike Leavitt, "Medical associations too others possess got begun the piece of work of developing character standards too cost measurement, but nosotros possess got many years of piece of work ahead of us to laissez passer on the wide-ranging too meaningful character standards nosotros need."[10]
• No mater what character measures are used, at that topographic point are complex issues to hold upward resolved, such as:
• At what betoken is at that topographic point sufficient confidence inward an evidence-based guideline that at that topographic point is no longer whatever demand to pass fourth dimension or coin on the continuous evaluation of its reliable too validity?
• When is a Definition of character also narrow, e.g., past times focusing on cost or symptom reduction, but non considering prevention, recurrence, coordination too continuity of care, or the patient-physician relationship?
• How do you lot mensurate character when resources are scarce too optimal aid for the community may require less than "the best" aid for its private members (e.g., delegating business office nurses to perform for certain activities that physicians used to do)?
• What is the best way to mensurate character if outcomes are to a greater extent than strongly affected past times patient compliance than past times physician orders? This may occur, for example, if for certain providers possess got personalities that trigger greater patient compliance, too visa versa.
• Is it miserable character aid if a provider follows the recommended practise guideline, but the patient is atypical too responds poorly? [11]
• Use of claims (administrative) information to mensurate aid character is grossly inadequate for many reasons.[12]
• As discussed earlier, assessing aid character using physical care for information may non hold upward valid since they do non necessarily reverberate aid outcomes.[13]
• One thorny number is how to avoid political too ideological biases when determining what evidence to work equally the footing for establishing the guidelines, since character aid is unlikely to hold upward achieved unless treatments are based on objective science.[14]
• Many areas of healthcare lack aid physical care for standards and/or character measures. That is, different healthcare disciplines too specialties require different types of information to evaluate quality. For example, it's foolish to mensurate the character of mental healthcare services alongside information appropriate for evaluating cardiologists' performance; too the same is truthful for a podiatrist, dentist, chiropractor, etc.-each demand different measures for determining quality, but they are oft lacking.[15]

We must bargain alongside these challenges too pitfalls before P4P incentives volition atomic number 82 to substantial aid character improvements. But fifty-fifty if P4P results inward to a greater extent than effective diagnostic too handling procedures, this increased higher character aid fails to address the job of high costs due to inefficiency, which includes wasteful over-testing, over-treating, too delivery of to a greater extent than expensive aid when less costly alternatives are just a effective, equally good equally inadequate focus on wellness/preventive care. Only the transformation to "Pay for Value" (P4V)--in which the most cost-effective (high-value) aid is rewarded--will brand healthcare to a greater extent than affordable too available.

Transformation to Pay for Value

Unlike P4P, P4V focuses on the human relationship betwixt diagnosis, treatment, clinical outcomes and cost to increment aid value through incentives for improving aid character and efficiency, i.e., cost-effectiveness. The transformation to P4V requires that we:

• Revamp our diagnostic system to course of instruction each patient to a greater extent than precisely
• Tailor handling guidelines to patient's individualized needs too preferences past times identifying too recommending the most cost-effective aid for each patient, including attending to the mind-body connection too appropriate alternative too complementary interventions
• Maximizing efficiency past times minimizing waste matter too paying strong attending to wellness & prevention
• Track patient's information across their entire lifetimes using comprehensive clinical outcomes too cost data.

If nosotros did this, nosotros would possess got patient-specific evidence-based guidelines defining the most cost-effective aid tailored to each patient's especial needs. We could too then vantage providers for rendering such high-value care. This is the essence of P4V.

Unfortunately, our province has non been moving inward the P4V direction because nosotros neglect to:

• Focus on supporting the kinds of inquiry too information systems necessary for generating too using the sort of evidence-based guidelines providers too patients demand to improve outcomes too command costs through greater character too efficiencies
• Reduce waste matter too expense past times selecting too implementing the most cost-effective aid options too prevention strategies.

This way that today's P4P programs are built on flimsy knowledge. In essence, nosotros are pretending that nosotros know (a) what each patient needs to rest good through prevention; (b) when ill, what each patient needs to larn good alongside to the lowest degree conduct a opportunity too complications; too (c) how to deliver such aid alongside the greatest efficiently too to the lowest degree cost.

Let's Stop Deceiving Ourselves

Pretending nosotros know what high-value (cost-effective) aid is too how to deliver it--as nosotros flounder inward a knowledge gap dominated past times ignorance too uncertainty too inadequate wellness information technologies--is a unsafe shape of self-deception. We are deceiving ourselves into believing that rewarding providers via P4P for next electrical flow twenty-four hours best practise guidelines is going to increment the character too cut the cost of aid when (a) inquiry shows that today's guidelines are neither personalized nor focused on cost-effectiveness too (b) next the guidelines do non necessarily termination inward improve outcomes, equally discussed earlier.

So, instead of pretending, nosotros should hold upward obtaining too using the noesis nosotros demand almost aid value past times investing to a greater extent than inward clinical inquiry (in both lab too field) too advanced information systems that furnish next-generation decision-support, collaboration, too continuity of aid capabilities. This way nosotros should hold upward focusing on transforming our electrical flow healthcare scheme to a value-based scheme that:

• Pays for the research, collaboration too information systems needed to establish, evolve, disseminate too work high-value, evidence-based guidelines that are tailored to each patient's especial needs.
• Offers fiscal incentives to the providers who engage inward this knowledge-building too utilization physical care for to deliver high-value care, rather than just rewarding those who follow today's inadequate guidelines.

Once we've established valid too reliable patient-specific best practise guidelines--which accept into concern human relationship both character too cost--then nosotros are cook to brand the transformation to pay for value (P4V). In the hateful time, nosotros ought non postpone P4P initiatives, equally long as:

• Clinicians who chose non to follow standardized guidelines for especial patients volition also have the vantage if they possess got a proficient argue for doing things differently
• Ample clinical too fiscal outcomes information are collected to determine the termination of next full general guidelines alongside especial patient types, so nosotros are able to brand them to a greater extent than personalized over time
• Built into the P4P methodology is an increased focus on rewarding clinicians who larn proficient results at a proficient price, too decreased focus on just next full general processes
• Money spent inward these early on P4P initiatives do non restrain spending on inquiry aimed at developing personalized guidelines too improve determination tools
• There is an explicit strategy to displace toward giving P4V rewards to multidisciplinary teams of clinicians who are involved inward treating the same patient, equally opposed to each private clinician, inward guild to promote improve continuity of care.

In other words, the transformation from today's P4P initiatives to P4V should hold upward based on a clear strategy to:

• Improve/evolve electrical flow evidence-based guidelines to hold upward always to a greater extent than personalized
• Make fiscal rewards increasingly based on clinical outcomes information reflecting high-value aid delivery
• Enhance collaborative efforts inside teams of clinicians promoting improve continuity of care.

In addition, P4V should include "shared determination making" augmented past times patient determination aids for achieving informed patient choice. This strategy would promote "a novel measure of practise for defining medical necessity for many discretionary treatments based on informed patient selection … [which is beneficial since] informed patients look to demand less surgery than the amount straightaway beingness performed … too the conduct a opportunity for serious medical mistake occasioned past times providing an unwanted therapy is greatly diminished."[16]

Failure to do these things tin do to a greater extent than damage than proficient past times making us complacent inward the belief that nosotros are doing enough, whereas inward reality, these early on P4P models do relatively petty when you lot realize what ought to hold upward done inward the long term to increment aid value!

Bridges to Excellence

There are potentially useful P4P models beingness offered, which tin foster the transformation to P4V. One such model, named Prometheus, is beingness proposed past times the Bridges to Excellence organization, a non-profit grouping of employers, physicians, wellness plans too patients working to create important leaps inward the character of healthcare. It focuses on a payment scheme that uses (a) "evidence-based illustration rates" that determine how much to pay providers based on the cost of the resources required to deliver aid according to evidence-based practise guideline, too (b) a comprehensive scorecard of character to pay to a greater extent than coin to providers who consistently follow for certain practise guideline processes, demonstrate proficient clinical outcomes, have high patient satisfaction ratings, too operate cost-efficiently.[17]

In my side past times side postal service inward this series, I beak over the Whole-Person Integrated-Care solution.

References:

[1] Rosenthal, M.B. (2007). Nonpayment for Performance? Medicare's New Reimbursement Rule. New England Journal of Medicine; 357(16):1573-5.
[2] Ibid.
[3] Rosenthal, M.B., et al. (October 2005) Early Experience alongside Pay-for-Performance: From Concept to Practice. Journal of the American Medical Association, 294 (14):1788-93.
[3a] Modern Physician Online (Sep 17, 2007). P4P programs' value questioned despite growth.
[4] Garber, A.M. (2005). Evidence-Based Guidelines As a Foundation For Performance Incentives. Health Affairs, 24, (1): 174-179 Available at Minneapolis/St. Paul Business Journal (Nov 19, 2007).
[6] Bradley, E.H., et al. (2006). Hospital Quality for Acute Myocardial Infarction: Correlation Among Process Measures too Relationship With Short-term Mortality JAMA;296:72-78. Available at Reuters (Sep 20, 2006). Elevated cholesterol may do goodness failing hearts.
[9] Gawande, Influenza A virus subtype H5N1 (2004). The Bell Curve. The New Yorker.
[10] Bush's Value-Driven Health Care Plan Gains Steam equally More Employers Step Up (May 10, 2007)
[11] Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691-729.
[12] Use of claims information is inadequate - WellnessWiki
[13] HealthDay (July 5, 2006). Hospital Ratings Don't Fully Reflect Patient Outcomes.
[14] Healy, B. (Sep. 2006).Who Says What's Best? the U.S. News too World Report.
[15] Need for specialy measures - WellnessWiki
[16] Wennberg, J.E., et al. (2007). Extending the P4P Agenda, Part 1: How Medicare Can Improve Patient Decision Making too Reduce Unnecessary Care. Health Affairs; 26(6):1564-74.
[17] Bridges To Excellence (2006). Prometheus White Paper - Paying for Excellence. Available at http://www.bridgestoexcellence.org/bte/wp_prometheus.htm

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