Wednesday, September 08, 2010

Pay for performance and motivation

An anonymous commenter on a post below asks:

Insurers have increasingly used pay-for-performance measure incentives for hospitals. Is there a sense that these will continue to expand?

I am not sure of the answer, but the question prompted me to give you a sense of the current P4P measures used by several of our private and government payers.

Here's a partial list:

Heart failure care processes (CMS measures)
AMI care processes (CMS measures)
Pneumonia care processes (CMS measures)
Surgical care infection prevention (CMS measures)
Patient experience with MD communication (H-CAHPS measures)
Patient experience with RN communication (H-CAHPS measures)
Patient experience with responsiveness of staff (H-CAHPS measures)
Patient experience with discharge planning and instruction (H-CAHPS measures)
Reducing surgical site infection -- colorectal population
Reducing surgical site infections -- GYN/hysterectomy population
Reducing surgical site infections -- orthopaedic trauma population
Reducing nosicomial catheter related urinary tract infections
Deploying rapid response teams (Triggers Program)
Preventing central line-associated bloodstream infections
Preventing ventilator associated pneumonia
Preventing pressure ulcers
Reducing MRSA infections
Preventing harm from high-alert medications
Preventing adverse drug events
Reducing surgical complications
Board of Directors training on quality and safety
Assessment of culturally/linguistically appropriate services
Assessment of health disparities

If you were in a management position and were trying to direct quality and safety improvement efforts, how would these guide your behavior? If your were a nurse or doctor and were trying to be responsive in focusing on quality and safety improvements, what would this variety of measures tell you?

Let me jump to the answers: The large number of overlapping measures, often with different definitions among payers, can cause confusion rather than offer guidance to hospitals in directing improvement efforts. That is especially the case because many of the items are "roll-ups" of several metrics in themselves.

In this respect, P4P measures are not always the most useful management tools by which to focus attention on the fundamental elements of process improvement: reduction in variation, redesign of work, and communication in clinical settings -- all in collaboration with patients and families. People who have studied how to achieve change in organizations point to the need for an overarching, audacious set of goals that are highly motivational.

In our case, the most important established goal is to eliminate preventable harm, one endorsed by our Board of Directors. This goal is combined with a strong commitment to transparency, so we hold ourselves accountable to the standard we have set. So, while we will always do our best to meet P4P requirements, many of which have clinical importance, we do so within an overall context that is meant to transform the organization.


Anonymous said...

Funny you should raise this point now, as this weeks JAMA has an interesting commentary on QI measurement and the perils of using evidence-based vs indicator-based metrics. It is short, but talks about this very issue and the untoward motivations that result from choosing unwisely.


Anonymous said...

Requires paid subscription. Would you please excerpt pertinent parts?

Anonymous said...

Difficult, as the piece works more as an intact entity, but a snippet:

"Public reporting creates an incentive to maximize performance but does not specify the manner in which this is achieved. Broadly speaking, 2 approaches are possible. Hospitals can adopt evidence-based strategies designed to improve patient outcomes that will also improve the publicly reportable indicator, or they can adopt indicator-based strategies designed to improve the reported indicator that may not improve outcomes and may even cause harm. Evidence-based improvement strategies would be favored in an environment in which organizations focus on improving patient outcomes—when such strategies exist and are easy to implement. Conversely, indicator-based improvement strategies would be favored in an environment in which the hospital focuses on protecting its reputation, when evidence-based improvement strategies are unproven or resource intensive, or when measurement of the indicator is easily manipulated to show improvement."

It focuses on hand-washing thereafter, as an illustrative example.

Also, a study published in same issue looks at P4P, "rankings" and such with docs caring for affluent vs indigent patients. After more nuanced adjustments, 1/3 of docs recategorized. Clearly, we are missing gobs in our risk adjustment.

Brad F

Anonymous said...

I cannot read the JAMA article either, but if it says anything similar to the "in defense of physician autonomy" op-ed in the WSJ, or to recent AMA remarks about quality metrics, or to recent blog posts (Kevin MD) about Don Berwick planning to run a Soviet-style health care system, I am skeptical.
Our profession needs to get busy and generate some quality metrics of its own, rather than railing against any and all forms of assessing accountability. We are just simply denying reality - either get control, or be controlled.

Paul's astonishing list of metrics in his post demonstrates exactly why we need to do this.

nonlocal MD

Anonymous said...

Sorry, not to hijack Paul's post, but I just ran across a (free!) NEJM editorial on public outcomes data on CABG, recently released to Consumer Reports by the American Society of Thoracic Surgeons:

This exemplifies my point - providers who have better data than administrative sources , taking the initiative to publicize it, good or bad. Improving care, diminishing harm, transparency.


Lynn said...

As a nurse who performed Core Measure AMI reviews (CMS Measures)for seven years I sincerely hope insurance companies move away from this practice. Results are heavily dependent on documentation in patient charts and do not truly represent the actual quality of the care given. CMS rules for documentation are cumbersome and lacking in clinical accuracy. The actual pay for performance is dependent on the reviewers performance to do accurate chart reviews and not dependent on the physicians performance. My hospital administration's lack of understanding about how Core Measure's works left me open to intimidation from a director of a service that was affected by my AMI review results. This forced me to leave my position to maintain my integrity and sanity. I was constantly being made a scapegoat for the hospital's results. Interrogations about how I did my reviews were never ending. Even though I knew the results did not truly represent our hospitals care, which was excellent, I was obligated to follow the CMS guidelines for documentation to ensure our hospital received 3% of it's full market basket.


Sheila said...

Treat every patient like s/he is a member of your own family. The reason, everyone is a member of "someone's" family.

Steve Massi said...

Sounds like 2 core issues here, one being measures, the second being the interpretation of care. I don't think they are the same. Roll-up metrics can be addressed through an accurate and sharable checklist-type practice set. PERCEPTION of Care is based on accurate, timely and empathetic communication between all hospital staff (even independent MD's are seen as hospital staff in a hospital setting) and patient and family (or caregivers).

Separate metrics of care can be used to measure these behaviors.

Matthew said...

From Facebook:

Hmmm. It seems to me that this kind of pay per performance thing is probably most useful when the outcome being measured is one of little personal significance or reality to the people doing the work. I can't imagine a nurse or a physician taking different actions because they'll get a bonus if the patient has a better outcome.

I don't know about health care workers, but from what I've seen incentive pay doesn't work with engineers, who are supposedly mercenary. I think its because engineers are more sensitive to the capital value of their skill set than they are to a bonus check in the pay envelope. Give an engineer a project that will make him a better, more marketable engineer if you want special effort.

I'd imagine the biggest challenge in a hospital would be the repetitive performance of exacting but uninteresting work that is nonetheless necessary to a good outcome. Even if the worker cares about the outcome, that doesn't prevent the task from being mind-numbing.

Medical Quack said...

Let's not forget pay for performance outside the clinical areas, like what happened to my mother who is a model patient and does everything right, but I also realize all patients are not like her including me not being as good at following directions.

The call centers to get folks in for those new no copay benefits are a little pushy here and it was too much of a strong arm approach. I know those folks are graded on how many appointments they make and have some p4p in those call centers as that's a dirt job to do.

Also, let's not forget the pharmacists at Walgreens who can make p4p from United too, and I hope this is done correctly without the strong arm approach too, otherwise it's take the wrong way. Good helpful information is should always be welcomed but not pushed on individuals with the wrong methodologies.

76 Degrees in San Diego said...

It is all very exhausting, isn't it?

Marco Huesch, MBBS PhD said...

Hi Paul

I just came across this piece in last month's Health Affairs about costs spent to address seven common diagnoses and associated reductions in mortality.

While this piece is looking at costs and outcomes for diagnoses, I think it speaks to the difficulty of matching safety improvement costs with outcomes.

It's at

One relevant snippet: "After adjusting for inflation, we found little correlation between reduced mortality for certain conditions and increased spending on patients with those conditions."

Another: "As a result, the cost to save one additional life-year as a result of improvements in care varied greatly within and across diagnoses, from as little as $11,900 for an elderly patient with acute myocardial infarction to more than $190,000 for a patient of similar age with sepsis."

As I was reading this, I was thinking of the extraordinary efforts your team puts into - among other efforts - reducing central line infections and thus reducing mortality from sepsis.

Do you think our field has an opportunity to try and get a sense for the return on investment on patient safety across different types of errors as well?

The manager in me wants to believe that there has to be some sort of prioritized list of efforts, perhaps by cost-effectiveness metrics or time to implement...


Anonymous said...


You stated that "People who have studied how to achieve change in organizations point to the need for an overarching, audacious set of goals that are highly motivational." Can you quote some of the studies that show this?


Anonymous said...

Thanks to Matthew - what you noted - that doctors are unlikely to change their practice for minor pay bonuses has actually been shown in decent studies. There is evidence that it harms or is neutral to care patterns, but no data that it improves care.

Nevertheless, the push to promote these things continues unabated and proceeds full steam ahead

Anonymous said...

These aren't pay bonuses to individual providers - but are P4P of insurers to hospitals for the quality of care they deliver. There are plenty of caveats and reactions to their use, but it speaks volumes about medicine that insurance companies and regulators have to lead the cart of quality improvement. Where's the patient's right to receive the highest quality of care? No one deserves autonomy over that responsibility.

76 Degrees in San Diego said...

The answer to the last question is that it is based on payment for the cost of providing the service.