or most goods and services, differences in prices reflect differences in quality, although the correlation may sometimes be absent. In health care, excellent and substandard services will often cost the same; purchasers may even pay more for lower quality. This anomaly has its roots in the third-party payment system that finances the delivery of health care. The employer or insurer pays for the service but does not know whether it has been a success, not being the patient. The absence of evidence-based outcomes measures exacerbates the difficulty of determining value.

Large purchasers of health care, both private-sector and governmental, are attempting to speed up the rate of quality improvement through the pay-for-performance, or “P4P,” concept. One major impetus was the 2001 Institute of Medicine (IOM) study Crossing the Quality Chasm. The IOM report laid out six fundamental attributes for a 21st-century health care system: Health care should be Safe, Timely, Effective, Efficient, Equitable, and Patient-centered (STEEEP).

The IOM principles have been implemented notably in the “Bridges to Excellence” (BTE) initiative. BTE is one of the 800-pound gorillas of the P4P movement. It is a not-for-profit corporation led by employer (General Electric, UPS, et al.) and health plan (e.g., United Health Care) representatives. Among its activities is:

How does P4P work? Three separate BTE programs are currently paying physicians a bonus for participating in specific quality-improvement activities. “Diabetes Care Link,” the first to be launched, offers physicians who are certified by the Diabetes Physician Recognition Program of the National Committee on Quality Assurance (NCQA) $100 per year per diabetic patient, plus the costs of certification. To be certified, a physician must meet specific goals such as having 55 percent of diabetic patients with HbgA1c below 8 percent. Diabetes Care Link also pays patients for compliance with their care regime.

Who funds these dollar incentives? Employers do, paying $150 per year per patient while realizing approximately $350 in savings per diabetic patient. When the first payouts were made to physicians in Cincinnati, Ohio, and Louisville, Kentucky, in November 2003, the amounts were in the thousands, the highest being $7,500.

BTE has a similar program for heart disease and stroke treatment called Cardiac Care Link, which also depends on certification of physicians by NCQA. Its third program, Physician Office Link, is quite different. This initiative rewards information systems capabilities such as certain electronic medical record elements. It also measures physician offices on patient education and support and care management (e.g., resources to help with medication compliance).

According to one consultant, there were about 80 P4P programs operating around the country in 2004. Many are organized by health plans, including a number of Blue Cross/Blue Shield affiliates. In Washington state, Premera Blue Cross, the largest health plan with 1.2 million subscribers, operates a quality scorecard system and a quality incentive program as well as a pharmacy incentive plan for 10 large clinics. The quality programs are based on compliance with screening (breast cancer, cholesterol levels in diabetics) protocols, patient satisfaction variables, use of appropriate medications for asthma, otitis media and acute bronchitis and other measures. Scorecard results will be published through physician and patient portals on Premera’s Web site. The quality incentive program pays physicians for achievement or improvement over the provider’s own annual baseline. Network comparative data also are published. The programs have been so successful that a county medical society has approached Premera seeking to participate.

American Medical News recently reported on a P4P plan introduced not by an employer group or a health plan but by a 4,800-doctor, 120-hospital preferred provider organization in Oklahoma City. This program offers cash incentives to both physicians and patients, similar to the BTE “Links.” PPO physicians can receive 30-percent to 50-percent higher fees by agreeing to follow a set of evidence-based guidelines developed by four major academic medical centers. Patients receive rebates on copayments if their physician participates in the program, an interesting form of leverage.

How might such P4P programs affect anesthesiology? The delivery of anesthesia is not a hugely tempting subject to those who wish to reward performance improvements because it has already become so uniformly safe and successful. Our real opportunities probably exist in perioperative care as well as in pain medicine and critical care.

Working with other specialties and with government agencies, members of the ASA Committee on Performance and Outcomes Measurement are exploring the evidence for perioperative care strategies designed to prevent surgical infection, adverse cardiac events and postoperative pneumonia. ASA is known for the quality of its evidence-based practice parameters, as mentioned in Dr. Sinclair’s article on page 8. Documented adherence to elements of those practice parameters, e.g., in the area of preoperative testing, could become a basis for rewards.

P4P is still in its infancy. The examples above of functioning P4P programs show that the concept is with us to stay, but there are innumerable directions in which it will continue to grow. Some very basic questions are still open, including the one at the forefront of physician representatives’ minds: Are some providers going to be paid less because of P4P? Among other fundamental questions are:

There are many parties attempting to develop the answers. On November 22, 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued its “Principles for the Construct of Pay-for-Performance Programs.” Motivated by the concern that proliferating P4P programs are largely untested, JCAHO enumerated a list of 10 major principles, including the following: alignment of P4P programs with “high-quality, safe health care for all consumers”; tailoring of incentives and a sliding scale of rewards; use of nationally accepted measures; use of evidence-based (or at least expert consensus-based), risk-adjusted metrics; minimization of burden; and coordination of goals and approaches “in units broader than individual provider organizations and practice groups.”

The National Quality Forum (NQF) has announced that it will hold a workshop to begin standardizing P4P program principles in early 2005, at the request of the Centers for Medicare & Medicaid Services (CMS). Again the reason is “increasing concern about the lack of guidelines, recommended criteria and structure and/or coordination among payer/purchaser entities.”

The NQF in 2003 endorsed a set of 39 voluntary consensus standards for hospital care quality. CMS selected a starter set of 10 of those standards for its Hospital Quality Initiative, and on November 30, 2004, the agency posted results on its Web site for more than 4,000 hospitals that had volunteered to participate in reporting their compliance with those 10 standards. The measures included such interventions at administering aspirin and beta-blockers to heart attack victims upon arrival and discharge. An additional set of 24 measures, including such perioperative services as antibiotic prophylaxis for coronary artery bypass grafting patients, is the subject of reporting in a CMS demonstration project with Premier Inc., a national organization of nonprofit hospitals. The demonstration aims to reward the top-performing hospitals by increasing their payment for Medicare patients.

This is just a small sampling of the P4P activities under way. Government bodies (CMS, Congress, the Agency for Healthcare Quality and Research, the Veterans Administration), private payers (the Blues, United and Aetna, to name some of the biggest), quality and provider organizations, health care purchaser coalitions (BTE, the Leapfrog Group) and health policy experts are all engaged in developing and implementing P4P programs. ASA leadership is focusing on the risks and opportunities for anesthesiologists and will involve the membership in the process.

Anesthesiologists who already have experience with P4P programs are invited to help educate me at <k.bierstein@ASAwash.org>.

Source Material:
• Bridges to Excellence Web site, with links to partner Web sites: <www.bridgestoexcellence.org>.

• National Quality Forum Web site: <www.qualityforum.org>.

• CMS Hospital Quality Initiative: <www.cms.hhs.gov/quality/hospital/>.

• JCAHO Principles for the Construct of Pay-for-Performance Programs: <http://jcaho.org/news+room/news+release+archives/jcaho_112204_principles.htm>.