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Improving Patient Care |

Pay for Performance Through the Lens of Medical Professionalism

Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Alice Gosfield, Esq; David Gregg, MD; Keith Michl, MD; David Wennberg, MD, MPH; Kevin B. Weiss, MD, MPH; and Eric C. Schneider, MD, MSc
[+] Article and Author Information

From the American College of Physicians and Alice G. Gosfield and Associates, Philadelphia, Pennsylvania; Gregg Consulting Services, Minneapolis, Minnesota; Maine Medical Center, Portland, Maine; American Board of Medical Specialties, Chicago, Illinois; RAND Corporation, Cambridge, Massachusetts; and Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts.


Disclaimer: The views expressed in the paper are solely those of the individuals on the advisory board and do not represent the policy of the American College of Physicians or the American Board of Medical Specialties.

Acknowledgment: The authors thank Lea Anne Gardner, RN, PhD, for her review.

Grant Support: By the American College of Physicians Diabetes Initiative, sponsored by an unrestricted educational grant from Novo Nordisk.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2164.

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Ms. Gosfield: 2309 Delancey Place, Philadelphia, PA 19103.

Dr. Gregg: 5305 Humboldt Avenue South, Minneapolis, MN 55419.

Dr. Michl: Box 1431, Manchester Center, VT 05255.

Dr. Wennberg: 39 Forest Avenue, Portland, ME 04101.

Dr. Weiss: 222 North LaSalle Street, Suite 1500, Chicago, IL 60601.

Dr. Schneider: 20 Park Plaza, 7th Floor, Suite 720, Boston, MA 02116.

Author Contributions: Conception and design: A. Qaseem, V. Snow, A. Gosfield, D. Gregg, K. Michl, D. Wennberg, K.B. Weiss, E.C. Schneider.

Analysis and interpretation of the data: A. Qaseem, K. Michl, D. Wennberg, K.B. Weiss, E.C. Schneider.

Drafting of the article: A. Qaseem, V. Snow, A. Gosfield, D. Gregg, K. Michl, E.C. Schneider.

Critical revision of the article for important intellectual content: A. Qaseem, V. Snow, A. Gosfield, D. Gregg, K. Michl, D. Wennberg, K.B. Weiss, E.C. Schneider.

Final approval of the article: A. Qaseem, V. Snow, D. Gregg, K. Michl, K.B. Weiss, E.C. Schneider.

Statistical expertise: A. Qaseem.

Obtaining of funding: V. Snow, E.C. Schneider.

Administrative, technical, or logistic support: A. Qaseem, E.C. Schneider.

Collection and assembly of data: A. Qaseem, K. Michl, E.C. Schneider.


Ann Intern Med. 2010;152(6):366-369. doi:10.7326/0003-4819-152-6-201003160-00006
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As the costs of health care and the number of uninsured Americans have increased, reform of health care payment systems has become an urgent national imperative. Pay for performance (P4P) has been proposed as one physician payment model. Under P4P, part of a physician's payments is earned on the basis of the quality of care, assessed by using explicit performance measures. The label “pay for performance” is applied to various financial incentive programs that differ in eligibility requirements, selection and scope of measures, formula for determining payment, and magnitude of payments (12).

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Provider Initiated Pay for Performance and Medical Professionalism
Posted on March 23, 2010
Dale N. Schumacher
Long Island Health Network
Conflict of Interest: None Declared

To the Editor:

"Pay for Performance Through the Lens of Medical Professionalism"(1) identifies four essential pay-for-performance themes (application of scientific evidence, ethical interactions, equity, and professionalism). The Long Island Health Network (LIHN) Provider-Initiated Pay-for- Performance Program (PI-PFP) is in its fifth year of operation(2) and has substantially incorporated these four themes.

LIHN is a clinically integrated network of ten hospitals under six separate governance structures. The PI-PFP was initiated in 2004 and is updated annually to ensure state-of-the-art efficiency, patient satisfaction, quality, and patient safety measures. Annually, an interdisciplinary Blue Ribbon Panel of internal and external experts and then quality directors and chief medical officers evaluate the prior year's experience and revise and improve the PI-PFP for the coming year. The Joint Planning Committee (the LIHN governance structure) approves the recommendations and, on occasion, makes the performance targets even more demanding. A percentage of commercial revenue is earmarked for at-risk dollars. Hospitals can earn back these earmarked dollars if both LIHN, in its overall aggregate performance, and the individual hospitals each reach the targets. If LIHN achieves the target but the individual hospital does not meet the target, the hospital can achieve payback of its individual hospital component by substantially improving its performance. Detailed algorithms calculate the aggregate LIHN performance and individual hospital payment for each measure. Funds that are not earned back are retained by the Network and are used for initiatives (e.g., physician and clinical integration) benefiting the member hospitals.

PI-PFP achieves Qaseem's et al. four themes. A high level of scientific evidence is required by the LIHN annual review and approval process. The process is ethical and transparent, with the governance structure having final approval authority over the process and the domain weighting. PI-PFP achieves equity as the performance metrics are calculated based on all individual patients' data and case mix adjusted. Lastly, in name and in process, this approach is a commitment to professionalism. PI-PFP is initiated by providers and enhanced, reviewed and approved by interdisciplinary provider teams; final approval is by the Network governance. As an internally-initiated program, we are able to rapidly implement enhancements and, thus, internally prototype proposed health care reform or payer initiatives. We are currently pilot testing readmission measures and expect to include readmissions in the 2011 PI-PFP program. Our PI-PFP program is driven by our quality commitment for the citizens of Long Island.

References

1. Qaseem A, Snow V, Gosfield A, Gregg D, Michl K, Wennberg D, Weiss KB, Schneider EC. Pay for performance through the lens of medical professionalism. Ann Intern Med. 2010 Mar 16;152(6):366-9.

2. Atkinson JG, Masiulis KE, Felgner L, Schumacher DN. Provider- initiated pay-for-performance in a clinically integrated hospital network. Journal for Healthcare Quality. 2010 January/February;32(1):40-50.

Conflict of Interest:

None declared

Re:Provider Initiated Pay for Performance and Medical Professionalism
Posted on March 28, 2010
michael Pauszek
None
Conflict of Interest: None Declared

TO THE EDITOR: Doctor Amir Qaseem's article in the March 16, 2010 issue of the Annals is an excellent reiteration of the conflict that has arisen between caring for patients and pay for performance. I applaud his group's thoughtful approach and recognition of our professionalism. Physicians have historically tried to provide the best of care. But physician status has eroded and the pressure to give in to patient demands has grown, especially with patient satisfaction surveying. Add the unquenchable patient complaint of pain and appetite for addictive substances and it is a formula for bad care. I would note that the article 's listing of patient satisfaction under the theme of application of scientific evidence does not seem appropriate. Patients cannot measure quality. I also do not totally agree with the premise that quality of care is lagging because of deficiencies in the US health care system. That is too simplistic. I support the concept of REAL pay for performance. I would not, however, define physician performance based upon compliance with "measures." Sometimes the measures used to make that argument, as an example the use of ACE inhibitors for all patients with diabetes, are still controversial. Conscientious physicians spend their professional lives and CME trying to find scientific evidence that can be applied to practice. But it is a constantly moving target. Instead the REAL measure of a physician's care is to appreciate the complexity of what happens when a physician sits down at the bedside to talk with a patient.

There in a time perfected careful exchange with the patient, the physician thoughtfully acquires a history while mentally evolving a diagnosis list. This is followed by a skilled physical exam used to refine the differential. If necessary, selective supplemental tests are obtained. With nothing more than these tools a skilled physician with the insight of years of training, defines the diagnosis and proposes a treatment plan to the patient. This is the physician's REAL performance. Has the US forgotten that this is the essence of what we do? That is the performance for which I want to be remembered.

How did we get to this point? Unfortunately we have allowed autistic third party payers and equally autistic medical administrators to herd us for decades. Like hapless frogs sitting in a medical reimbursement pot, the temperature has been gradually turned up over the years and we have sat, grumbling but submissive, having our life force cooked away. The change has been gradual but unremitting. We have not had the courage to hop out. Now we are all cooked. Need examples; private practice has followed the path of the dinosaur to extinction. We cling to the hope that Congress will not allow Medicare payments to be reduced. Not be reduced as overhead and practice costs escalate. When did we get so passive? It is time to say stop! It is time to say NO! How did patient care slip from our hands? When did our profession slip so low that fibromyalgia and pseudoseizures got the credibility of diseases? Let us have REAL evidence based medicine and reward good practitioners for the care they provide.

Reference

1. Qaseem A, Snow V, Gosfield A, Gregg D, Michl K, Wennberg D, Weiss K, Schneider E. Pay for Performance Through the Lens of Medical Professionalism. Annals of Internal Medicine. 2010; 152:366-369

Conflict of Interest:

None declared

Professionalism as a Pendulum to Pay for Performance in the Changing World
Posted on May 10, 2010
Antonino Gullo
Department of Anaesthesia and Intensive Care. Catania School of Medicine, Catania, Italy
Conflict of Interest: None Declared

Medicine integrity may be influenced by political and economic considerations in the changing world. We appreciate to read the interesting paper by Qaseem and coworkers (1); we offer briefly reflections and our personal point of view on medical professionalism according with physicians specialty, practice setting, and to pay for performance trials. We are in the era of commercialism, consumerism, bureaucratization and industrialization! Competencies are characteristics of a person that cause superior performance of resource allocation and rationing. Problems to pay for performance include internal inequality and the potential for misuse. People bitterly experienced that competence often is not tuning with performance.

An erosion of public trust in the professions has brought increased attention to medical professionalism; it aspiring those skills, attitudes and behaviours which we have come to expect from individuals during the practice of profession and includes several concepts such as maintenance of competence, ethical behaviour, integrity, honesty, relationship, responsibility, accountability, altruism, caring and compassion, service to others, adherence to professional codes, justice, respect for others, self regulation, scientific knowledge, excellence and scholarship, and leadership. No codes exists in the physician charter of medical professionalism (2) to pay someone for performance!

The use of such systems without guidelines or recommendations remain controversy. Is still to demonstrate that pay for performance determine a better quality of care, patient satisfaction and cost saving; one potential bias concern that the health care system pay more than the salary for covering the gap caused from shortage of qualified staff; in other words, this kind of economic incentives could become a organizing model which can turned in an obligation, under some group of pressure who don't like quality, that grew an infinite cost escalation in the time of finite resources.

Physicians, nurses and all allied people, thinking in their mission, continue to express high reputation in the figure of Sir William Osler (3) who preconized the era to pay for performance : medicine is "a calling not a business."

References

1.Qaseem A, Snow V, Gosfield A, Gregg D, Michl K, Wennberg D, Weiss KB, Schneider EC. Ann. Int. Med. 2010 mar 16; 152(69:366-9

2.ABIM Foundation. American Board of Internal Medicine. Medical Professionalism in the New Millennium : a Physician Charter. Ann. Intern Med. 2002; 136:243-6.

3.Osler W. Medicine is a calling not a business. The Reserve of Life. St. Mary's Hospital Gazette 1907

Conflict of Interest:

None declared

P4P: What Medical Professionalism Needs
Posted on May 10, 2010
Carla Saenz
Department of Bioethics, CC, NIH
Conflict of Interest: None Declared

The authors successfully show that the professional responsibilities are compatible with pay for performance (P4P). We agree with their analysis but believe that a stronger claim should be made: P4P is not merely compatible but actually required by the primacy of patient welfare, which according to the Physician Charter is a fundamental principle of medical professionalism.(1)

In the fee-for-service system physicians' payments are aligned with the quantity of services they provide, thereby creating financial incentives to deliver a higher number of services. More services however do not necessarily constitute better care for patients. Indeed, there is evidence that more services may lead to worse health outcomes.(2) Furthermore, fee-for-service disincentivizes the delivery of non-procedure based treatments that greatly impact patients' health, including many aspects of preventative medicine.

P4P aligns the physicians' payments with the quality of care they deliver. It thus creates a financial incentive to deliver the best possible care to patients. If physicians are committed to the primacy of patients' welfare, and there is a payment system that advances patients' welfare, then they should adopt that payment system. The adoption of P4P is thus required by professionalism's principle of the primacy of patients' welfare.

Moreover, the Charter attributes a role to the profession as a whole, which further justifies the endorsement of P4P. It explicitly states that the system should facilitate physicians' adherence to professionalism: "the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal" (Charter, 244). "[T]heir active dedication to the principles of professionalism ... entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society" (Charter, 246).

To that extent, the medical profession should make every effort to adopt this payment system that facilitates and rewards physicians' adherence to professionalism, which under the current system comes at the expense of their financial interest. P4P, on the contrary, aligns the interests of patients and physicians.

The Affordable Care Act advances the adoption of a quality-based payment system. The medical associations should support these efforts by e.g. investing on the development of quality measures, guidelines, and health information technology. They should not miss the extraordinary opportunity to have a positive and substantial impact on the health of the population, thereby advancing genuine professionalism.

Disclaimer: The opinions expressed here are the authors' and do not reflect the policies and positions of the National Institutes of Health, the U.S. Public Health Service, or the U.S. Department of Health and Human Services.

References

(1) American Board of Internal Medicine Foundation; American College of Physicians - American Society of Internal Medicine Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6.

(2)Brownlee, S. Overtreated. Why Too Much Medicine is Making Us Sicker and Poorer. New York: Bloomsbury; 2007. Emanuel, E. Healthcare, Guaranteed. New York: Public Affairs; 2008.

Conflict of Interest:

None declared

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