Incentive Strategies in Pay for Performance

2010 - 2 August - Pregnancy in the ICU
Aryeh Shander, MD, FCCM; Brenda G. Fahy, MD, FCCM; Lisa Kirkland, MD, MSHA, CNSP
The Society of Critical Care Medicine’s Pay for Performance Subcommittee recently surveyed members to assess their interest in and knowledge of P4P programs as well as their desire for future educational resources.
 
The Society of Critical Care Medicine’s (SCCM) Pay for Performance (P4P) Subcommittee recently surveyed members to assess their interest in and knowledge of P4P programs as well as their desire for future educational resources. The results show a membership interested in learning more about P4P initiatives. The subcommittee will fulfill this need through a variety of efforts, including Critical Care Congress sessions, articles in Critical Connections, podcasts, Webcasts and other initiatives. Results of the survey included:
  • More than 70% do not participate in P4P because their institutions do not have programs or they are not aware of such programs at their institutions.
  • Of the 30% who participate in P4P programs, half submit P4P-based bonuses as a group practice.
  • About 52% of respondents were aware of the Centers for Medicaid & Medicare’s value-based purchasing (VBP), a strategy to link payment more directly to the quality of care provided and to transform the current payment system by rewarding providers for delivering high-quality, efficient care.
  • More than 90% are seeking additional educational materials related to P4P and VBP, as well as their potential income implications.
Of the survey respondents, 75% were physicians, 16% nurses, 4% pharmacists, and 2% respiratory therapists (RTs) and physician assistants (PAs). While physician and nurse responses mirror the Society’s demographics, RTs and PAs were underrepresented in the results. Most respondents (61%) were employed at academic medical centers, while others were from community medical centers (11%), private practices (10%), and hospitals (29%). Thanks to all SCCM members who participated in this survey.
 
Pay-for-performance (P4P) programs seek to improve patient care by offering incentives for achieving pre-defined quality measures. A P4P incentive strategy should fulfill a program’s goals while being flexible enough to accommodate real-world variations.
 
Incentives can be tied to a threshold, tiered or graduated levels of reward, or relative measures (e.g., peer ranking or improvement from baseline). Some programs set a minimum threshold of achievement across all incentive measures. To qualify for an additional reward, an organization must achieve 80% to 90% compliance in all P4P measures; this methodology reinforces tight communication, as one area’s failure to meet targets reflects negatively on the entire group.
 
Incentives can target individual providers, groups, institutions or combinations of these depending on the quality measures. Who qualifies for the incentive will depend on the improvement area, nature of the care, and other practical issues. Incentives targeting individual providers are more limited in scope and thus typically are easier to manage; a small sample size may produce measurement inaccuracies, but these will be corrected as the sample size increases over time.
 
A balanced mix of financial and non-monetary incentives may provide the best approach to structuring the P4P program, although some advocate for penalties alongside rewards. Regardless of the type, incentives should be transparent and easy to understand. Examples of non-monetary incentives include administrative support, performance profiling and publicizing performance on key quality measures.
 
Several factors should be considered in determining the size of financial rewards in a P4P program, including specific provider characteristics, nature of the target clinical condition(s), environmental variables and existence of other incentives. The strategy can be designed to be budget-neutral, such as redirecting funds from poor to high performers, sharing the expected savings as a result of improvements and providing additional funds for P4P incentives.
 
Timing can impact the effectiveness of incentives. Large lump-sum rewards accumulated over time tend to be more noticeable to the provider, but their impact on everyday practice may be limited compared to smaller per-service/per-case incentives.
 
In critical care, these general considerations must be viewed in light of the inherent acuity and complexities of the patient population and the multiprofessional nature of the care provided. Many P4P programs focus on chronic illnesses and allow for interventions years after treatment. This is in contrast to the short-term interventions in the face of imminent morbidity and mortality common in critical care. Some recommendations to tailor P4P programs to critical care include risk adjustment of outcomes measures and incentives directed to multispecialty groups in charge of care, rather than to individuals.
 
When designing or comparing P4P programs, ample consideration must be given to factors related to provider, disease/condition, environment and patient. Reallocating funds based on a P4P program may result in degradation of the quality of care in socioeconomically deprived populations, as providers serving these populations tend to be faced with more challenges (e.g., documentation, compliance) compared with those serving more affluent populations. It is important not to lose sight of the ultimate goal: driving equitable improvement of the quality of care.