As much as possible, we need to have input into program design, and should always suggest measures that fall more clearly within our domain, over which we have more control. However, measures that overlap 2 specialties are not necessarily bad. We will share the credit even if the primary-care physician (PCP) is the one who gets the patient to go for her mammogram—and the likelihood that the patient will be motivated to do so will be doubled, because both the PCP and the ObGyn will be recommending it.
We also need to recognize that P4P is already a certainty for many of us. That means someone is defining the measures by which we’ll be judged—and it might as well be us.
Private payers will have big impact
Although the Center for Medicare and Medicaid Services (CMS) is working with various physician groups and health organizations on several demonstration projects,5 its programs are complicated and not germane to many ObGyns at this time. We will see far greater impact on our practices from the private-payer P4P programs that are coming.
Most programs start simply
A typical privately sponsored P4P program usually starts off relatively simply and then, upon review (usually annually), is modified as the capabilities of both the sponsor and participants expand. One major insurer (a national payer) has a program that tracks several “process measures” (as opposed to “outcomes”). These include:
These are all HEDIS measures, and the plan itself is measured through them and other factors by the National Committee on Quality Assurance (NCQA). Accomplishing these goals is good not only for our patients (because they are undergoing appropriate screening), but also for the plan, whose NCQA ratings will improve as a result of improved HEDIS compliance.
The program also measures the extent to which a group adopts technology such as electronic medical records (EMRs), electronic health records, e-prescribing, and an electronic disease registry. This last item can be something as simple as a recall system within the larger practice-management system to ensure that patients with abnormal Pap tests, mammograms, and other lab studies are not lost to follow-up.
First, learn to walk
As in the example above, a program should start with several easy-to-measure indicators, such as processes that are either done or not done, whose performance can be tracked through administrative (billing) data. After some attention is focused on these indicators and as goals are reached, the indicators may continue to be monitored or be put aside for a variety of reasons. Gradually, other, more sophisticated measures will be introduced.
The program should mature as our experience grows and data systems improve so that, ultimately, we look at true indications that quality has improved—better outcomes, hopefully at a lower cost.
Emphasis on generic drugs will save dollars
For many plans, increases in generic pharmacy utilization will be rewarded. Now, the cynics among us might conclude that P4P is really all about saving money for the health plans. Remember, however, that most plans have tiered copays for prescriptions, and the patient herself will save a substantial amount in copays if you can prescribe a generic alternative—particularly in high-volume pharmaceutical areas.
Also realize that, if we want a P4P program to reward participants without taking away from those who don’t achieve their goals, the money has to come from somewhere. Savings generated from a successful pharmaceutical program can drive the P4P program and pay for more substantial rewards.
How your patients benefit from P4P
Assuming a program actually gets us to change our behavior in a positive way, it should result in improved quality of care. This entails obvious benefits for our patients, such as when we succeed in getting a woman to obtain a mammogram. Let’s say the P4P incentive to increase the rate of mammography leads us to change our office workflow and actually make the mammography appointment for the patient before she leaves our office. This may “cost” us a bit more staff time, but it will help us meet a goal that will increase our return from the P4P program and help the patient get a needed service.
We briefly touched on the reduced cost of generic drugs, which has the potential to save the payer incredible sums of money. But this reduction in cost has benefits for the patient, too, who may appreciate the lower out-of-pocket cost of generic drugs.
My experience: Better postpartum depression, chlamydia screening
Last year, one of our programs included a measure of postpartum depression screening. To meet the goal, we developed a brief worksheet that included the Edinburgh Depression Scale. This worksheet was distributed throughout the practice, and almost everyone used it at the postpartum visit. Our doctors and midwives were amazed at the number of cases of even mild to moderate depression that were discovered using this tool, and felt they had truly improved the quality of care by performing this screening more formally.