By Adam Sonfield
Senior Public Policy Associate
Attempts to redesign the ways in which insurance in the United States pays and incentivizes health care providers have accelerated in the wake of the Affordable Care Act (ACA). At the center of many of these attempts is the concept of pay for performance (P4P), under which providers are rewarded not merely according to how much care they provide, but for the quality and impact of that care. As P4P initiatives expand across Medicaid and private-sector insurance plans, it seems clear that family planning providers must take P4P into account and vice versa.1
P4P initiatives typically use data-based financial incentives toward the goals of better quality care, better health outcomes, and lower costs.2 Measures of better care might look at whether the services and information provided are in line with medical best practices, along with patient satisfaction and provider benchmarks such as staff credentials and appointment wait times. Measures of better health involve patient health outcomes, sometimes adjusted for the patient’s initial condition and other factors outside of a provider’s control. Measures of cost are typically assessed on a per-patient basis, with the expectation that high-quality care, such as effective preventive care, might result in savings.
Providers that surpass thresholds for quality, outcomes, and costs — or that improve over time or in comparison with their peers — might receive additional reimbursement under a P4P initiative. Alternatively, providers might be penalized if they fail to reach such thresholds or standards. P4P initiatives might be freestanding or might be part of broader care coordination models that have expanded with ACA funding.
Many potential P4P measures, such as those around patient satisfaction and appointment wait times, are just as applicable to safety-net family planning centers as they are to other healthcare providers. Yet, the range of available measures on standards of care and health outcomes is more problematic.1 There are commonly used measures related to chlamydia screening, cervical cancer screening, and human papillomavirus vaccination, each of which is an important family planning–related service. However, the major established performance measures — included in the Healthcare Effectiveness Data and Information Set (HEDIS) and endorsed by the National Quality Forum — don’t yet include measures related to contraceptive services and counseling or the prevention of unintended pregnancy. Without them, P4P initiatives cannot fully assess a provider’s performance and provide appropriate QI incentives.
One effort to address this gap comes from the Office of Population Affairs (OPA) and the Centers for Disease Control and Prevention (CDC), which are developing several contraception-related measures and working toward an endorsement from the National Quality Forum as early as 2015. OPA staff members also are working through Integrating the Healthcare Enterprise, which is an international organization that establishes standards used by EHR system vendors for encoding and transmitting data. They are working on family planning-related variables, such as pregnancy intention and current contraceptive method.3 Public comments on those variables were collected in spring 2014. These efforts are aimed at enhancing QI initiatives by government programs, health plans, and family planning providers. Some of the measures also might be adapted for use in P4P initiatives.
Officials in Oregon are also making progress on incorporating family planning into P4P. The state’s Medicaid program is organized around Coordinated Care Organizations (CCOs), each of which has a contract to organize Medicaid services for a region of the state. The system uses P4P quality measures to incentivize the CCOs and their providers. For 2014, the state is using population-level survey data to assess CCOs’ performance related to a state-designed measure on effective contraceptive use among women at risk of unintended pregnancy. That current measure is not tied to dollars, but for 2015, the state is switching to a similar contraceptive measure using patient-level data under the P4P part of its initiative.4 Specifications for the measure are still in the works.
Beyond the selection of specific performance measures, there are several other aspects of P4P initiatives that might matter for family planning providers and their clients.1 For example, the incentives in a P4P program must be designed appropriately, so as not to penalize safety-net providers for serving disadvantaged patients at a heightened risk of poor outcomes or to give providers a financial stake in the methods their clients choose. If designed well, P4P initiatives might provide family planning centers with new reasons and opportunities to expand their ongoing efforts to assess and improve quality of care, adopt new clinical technologies and techniques, bolster their staff members’ skills and their physical and electronic infrastructures, and integrate better with health plans and other community providers. Clinics would be able to attain greater stability and financial security, and clients would be able to rely on access to quality reproductive healthcare.
- Sonfield A. Pay-for-performance: making it work for safety-net family planning centers and the clients they serve, 2014. Guttmacher Policy Review; 17(2):8-13.
- James J. Health Policy Brief: Pay-for-Performance. Bethesda, MD: Health Affairs; 2012. Accessed at http://bit.ly/1oOVTAI.
- Office of Population Affairs. The Voice for Family Planning In Health IT. Accessed at http://1.usa.gov/1wlIuFd.
Bellanca HK. Health Share of Oregon. Portland, OR; personal communication; Sept. 11,