Pay-for-quality movement expanding nationally

But a supreme cynicism’ still pervades

Examples of the new emphasis on the quality of care are springing up around the country.

Last summer, Boston’s Harvard Pilgrim Health Care signed a four-year contract with Partners HealthCare Systems, giving Partners’ 1,000 primary care physicians and 3,000 specialists financial bonuses for taking preventive measures such as ensuring diabetes patients get regular eye and kidney check-ups.

In Indianapolis, Anthem, Inc., is reportedly creating a compensation system that pays physicians and hospitals based on meeting pre-set clinical and preventive health standards.

Jumping on the quality bandwagon, a major Florida managed care coalition now says it is willing to pay higher fees to physicians who achieve the best clinical outcomes. Under the Central Florida Health Care Coalition’s proposal, physicians would be divided into platinum, gold, or silver categories based on their documented outcomes for 10 specified conditions. The Orlando-based coalition represents 145 employers covering more than 1 million people.

Florida Coalition’s Targeted Conditions
The Central Florida Health Care Coalition is considering adjusting physician fees based on clinical outcomes for 10 targeted conditions treated in doctors’ offices that it says are the most costly and debilitating for its employees. These conditions are:
Lower respiratory infection
Sinusitis
Hypertension
Lipid/cholesterol disorder
Abdominal pain
Chest pain
Lower back pain
Diabetes
Depression
Ischemic heart disease/angina

Risk-adjusted claims data on office visits would also be used to create a profile of treatment patterns and clinical results for some 5,000 physicians in five specialties.

To earn a top rating, doctors also must meet such additional requirements such as participating in annual mini-residencies to ensure they’re up to date on the latest treatment techniques.

The decisions on how — and if — to proceed will depend on the results of a pilot program designed to test payment measures and an actuarial analysis.

Early indications are that reimbursement rates could vary from 70% of the current Medicare rate for silver physicians to 120% for platinum doctors willing to treat more patients with chronic illnesses, estimates the coalition’s head, Becky J. Cherney. To push more members to top-ranked physicians, their associated copayment would be reduced. "This is our way of saying we’re willing to pay doctors more for being a good physician," says Cherney.

Not all doctors who work with managed care are buying this idea, however. "The HMOs are still trying to nickel-and-dime doctors" when you compare what could be saved from more effective care that keeps people out of the hospital, maintains family physician Joseph W. Gallagher, MD, of Los Angeles.

There is a "supreme cynicism" among physicians across the country that no corporate purchaser really cares about medical quality, says William F. Jessee, MD, CEO of the Medical Group Management Association in Englewood, CO.

A major complaint is that many of these so-called quality compensation proposals don’t really pay directly for better care. Instead, they attempt to drive more patients to top-performing physicians. However, there’s no hard evidence that even this goal is being accomplished. Others complain that what direct bonuses do exist are geared to patient satisfaction surveys rather than hard clinical data. There’s also the question of whether mutually agreeable performance measures can be calibrated. Plus, a significant number of payers must switch to quality performance measures before the provider side of the equation starts to take the issue seriously, say experts.

"Experiments aimed at both holding providers accountable and encouraging them to practice quality medicine are happening across the country," notes benefits consultant Helen Darling of New London, CT. "Figuring out how to do this is going to be tough."