Index
A
Access to care
performance measurement and, 6
potential adverse consequences of payment incentives, 4–5, 29, 48–50
Accountability
for coordination of care, 120–121, 123–124
goals of payment system reform, 8
public reporting for, 10–11, 103–104, 106
Adverse consequences of pay-for-performance system
inequitable or decreased access, 29, 48–51
monitoring rationale, 4–5, 48, 53, 54
obstacles to knowledge transfer and innovation, 4–5, 29, 51–52
provider attitudes and perceptions, 52–53
Agency for Healthcare Research and Quality, 126
Ambulatory care Quality Alliance, 39, 179
Ambulatory payment classification, 146
American Health Information Community, 126
Anthem Blue Cross and Blue Shield, 22
B
Bridges to Excellence, 40–41, 62, 67
Physician Practice Connections, 41
Bundled payments, 4, 26, 33, 35, 145
C
Case management, 33
Centers for Medicare and Medicaid Services
current payment incentive programs, 3, 62
leadership for health care improvement, 28, 137
performance reporting program, 11–12
recommendations to improve coordination of care, 13, 122
See also Medicare
Certification and licensure
Medicare provider qualifications, 25
payment incentive programs and, 5
Certification Commission for Healthcare Information Technology, 128
Chronic heart failure, 180
Clinical quality
as basis for performance reward distribution, 81–83, 95–96
goals of payment system reform, 3, 20, 21–22, 44
Collaborative efforts, 39
Competition, in health care delivery system, 29, 52
Connecting for Health, 126
Consolidated Health Informatics, 126
Consumer Assessment of Healthcare Providers and Systems, 87, 109, 209–219
Coordination of care
accountable source of care, 120–121, 123–124
goals of payment system reform, 3, 8, 45
importance of, 124
performance measurement, 45
rationale, 13
rewards for, 123
shortcomings of current delivery system, 1, 4, 33, 45, 119–120
Coronary artery disease, 180
Cost of care
federal spending, 24
goals of payment system reform, 3, 21–22
health information technologies, 127
hospital management strategies, 145–146
international comparisons, 19
quality of care and, 19
Crossing the Quality Chasm: A New Health System for the 21st Century, 1, 15, 71, 81
D
Data collection and management
data auditing, 103
health information technologies, 124–129
limitations of current efforts, 88–89
Medicare data collection efforts, 43
Medicare demonstration projects, 38–39
pay-for-performance implementation, 5, 13, 103
provider feedback, 103
for quality improvement, 13
recommendations for, 14, 128–129
See also Performance measurement;
Public reporting
Demonstration projects, 3, 14, 22, 38–39, 139–140
Department of Health and Human Services
current payment incentive programs, 3
information technology promotion, 14, 126, 128–129
monitoring of pay-for-performance program, 14, 134
public reporting role, 10–11, 106
recommendations for, 6, 8, 10–11, 12, 14, 55, 78, 85, 106, 116–117, 128–129, 134
Diagnosis-related groups, 145–146
Dialysis, 19
Dialysis facilities
Medicare prospective payment system, 148–149, 208
Medicare spending, 19
pay-for-performance implementation, 110, 209–211
performance measurement, 208–209
Diffusion of knowledge and best practices
health information technologies, 124–128
payment incentive program as obstacle to, 29, 51–52
Disease management models, 38–39
Distribution of rewards
to ambulatory care settings, 215
among Medicare parts, 97
condition-based system, 89
defining comparison groups for, 94–95
to dialysis facilities, 211
graduated vs. fixed reward amounts, 92–93
to high-performing providers, 41, 84, 85, 101
level of award necessary to affect behavior, 46–47
performance improvement as basis for, 9–10, 83–85, 100–101
private sector pay-for-performance programs, 40–41, 62
provider payout case example, 97–100
to providers meeting performance thresholds, 90–91
public reporting and timing of, 107
size of reward, 100
structural measures for, 90
tournament-style reward structure, 91
for treatment of high-risk patients, 50, 129
E
Educational interventions
current payment system, 25
shortcomings of current payment system, 4
shortcomings of Medicare reimbursement, 33
See also Clinical quality
Efficiency of care
as basis for performance reward, 81–83, 95–96
goals of payment system reform, 21–22
performance measurement, 6, 51, 209
recommendations for payment incentive program design, 9, 82
shortcomings of current payment system, 4
Electronic health records, 6, 88, 124, 125, 127–128
Equitable care
potential adverse consequences of payment incentives, 4–5, 50–51
Excellus Blue Cross Blue Shield, 72
F
Fee-for-service system, 34
Funding for payment incentives
budget-neutral approaches, 65
challenges to establishing, 61–62
criteria for assessing possible sources, 60, 64–65
direct investment model, 71–74, 75
existing funds model, 66–69, 75, 77, 78
generated savings model, 69–71, 75, 78
performance reporting incentives, 106
private sector models, 62
public sector models, 62
research needs, 75
reward pool design, 60–61, 65, 67, 75, 78
reward size and, 100
short-term implementation, 65–66, 74–75
significance of, for pay-for-performance implementation, 6, 60–61
single source of, 8
H
Harvard Pilgrim Health Care, 62
Hawaii Blue Cross and Blue Shield, 22
Healthcare Information Technology Standards Panel, 126
Health Insurance Portability and Accountability Act, 13, 124
Health maintenance organizations, 41
HealthPartners, 73
Health plan care
pay-for-performance implementation for, 215–216
Health Plan Employer Data and Information Set, 39–40, 87
Heart/Stroke Physician Recognition Program, 41
Hemodialysis. See Dialysis
High-performing providers
basis for distribution of incentive rewards, 84
recommendations for reward distribution, 9–10, 85
relative comparisons, 91
Hill Physicians Medical Group, 41
Home health agencies
Medicare prospective payment system, 34–35, 147–148
Medicare public reporting efforts, 104, 105
pay-for-performance implementation, 11, 110, 217–218
performance measurement, 148, 216–217
Hospital Quality Alliance, 39
Hospitals
health information technologies, 125
Medicare prospective payment system, 34–35, 37, 145–146
Medicare public reporting efforts, 105
Medicare qualifications, 25
pay-for-performance implementation, 11, 110, 211–212
performance measurement, 211
I
Implementation of payment incentives
in ambulatory care settings, 213–215
benefits of collaboration, 39
challenges, 23
in dialysis facilities, 110, 209–211
funding pool considerations, 60–61, 65
health information technologies in, 13–14, 124–129
in home health care, 11, 110, 217–218
in hospitals, 110, 211–212, 217–218
Medicare restructuring to foster nationwide change, 27–28
monitoring, 12, 23, 44, 53, 54, 133–134
organization size as factor in, 115, 117
participation requirements, 112–116
performance measures, 6, 110–111
phased approach, 5, 6, 28, 29, 55, 107, 110, 117
procedural and technical issues, 101, 102
public reporting of performance outcomes, 10–11, 103–106
recommendations, 6, 12, 29–30, 32–33, 54–55, 75
research needs, 23
short-term funding models, 65–75
in skilled nursing facilities, 111–112, 219
specialist participation, 117–118
variation across settings, 11–12, 27, 110–112, 116–117
See also Funding for payment incentives
Infant mortality, 19
Innovation
goals of payment incentives, 3
potential adverse consequences of payment incentives, 4–5, 52
Integrated Healthcare Association, 22, 39–40, 62
International comparisons, 19
See also United Kingdom
L
Learning organizations, 135–137
Learning system, 6, 14, 54, 55–56, 133–134, 135–137
Life expectancy, 19
Longitudinal measures of quality, 12, 18, 116
M
Massachusetts Blue Cross Blue Shield, 62
Medicare
current payment system, 4, 22, 23–26, 33–34, 55
current public reporting efforts, 104–105
data collection, 43
distribution of rewards among component parts, 97
financing, 23
funding for payment incentives, 7–8
future challenges, 20
hemodialysis spending, 19
implementation of payment incentives, 6, 23, 27–28, 55
influence of, in health care system, 26, 28, 43
model reward distribution using existing funds, 67
Physician Fee Schedule, 35
program assessment role, 136
prospective payment system, 34–35, 38, 145–151
provider qualifications, 25
Quality Improvement Organization, 18
recent pay-for-performance experiments, 38–39
recommendations for pay-for-performance implementation, 6, 55
retrospective payment system, 34
scope of participation and benefits, 4, 23–24, 28, 147
utilization patterns and trends, 13, 19, 119
See also Centers for Medicare and Medicaid Services
Medicare Advantage program, 4, 11, 24, 33, 105, 110, 150–151
Medicare Management Performance Demonstration, 38–39
Medicare Payment Advisory Committee, 67, 110, 146, 180
Medicare Prescription Drug, Improvement, and Modernization Act (2003), 2, 17, 39, 148
Medicare’s Quality Improvement Organization Program: Maximizing Potential, 2, 18, 135
Medicare Trust Funds, 7
Monitoring of payment incentive programs
for distribution of rewards, 8
learning system approach, 6, 14, 54, 55–56, 133–134, 135–137
payment incentive program implementation, 6, 12, 116–117
rationale, 4–5, 14, 23, 44, 48, 53, 54
scope of, 133
Mortality studies, 46
N
National Commitee for Quality Assurance
Diabetes Physician Recognition Program, 41
Heart/Stroke Physician Recognition Program, 41
Physician Practice Connections, 41
National Health Information Network, 126
National Quality Coordination Board, 18, 140
Nursing homes
Medicare payment system effects, 38
Medicare public reporting efforts, 105
See also Skilled nursing facilities
P
Pathways to Quality Health Care, 2, 17, 44, 116
Patient-centered care
ambulatory care performance assessment, 213
as basis for performance reward, 81–83, 95–96
dialysis services assessment, 209
goals of payment system reform, 21–22
health plan performance assessment, 216
home health agency performance assessment, 217
hospital performance assessment, 211
measurement, 20
performance measurement considerations, 6, 51
recommendations for payment incentive program design, 9, 82
shortcomings of current payment system, 1
trends, 20
Pay for performance
barriers to provider participation, 11–12, 116–117
common features of existing programs, 42–43
experiences outside of health care sectors, 47
for high-performing providers, 9–10, 85
to improve coordination of care, 13, 122
performance improvement linkage, 2, 5, 17, 22–23, 26, 29, 36–37, 46
programs in United Kingdom, 42
quality improvement goals, 9, 20
stakeholder position statements
purchaser and consumer groups, 177–178
in systemic approach to health care reform, 5–6, 20, 27, 28, 44, 55
See also Adverse consequences of pay-for-performance system;
Distribution of rewards;
Funding for payment incentives;
Implementation of payment incentives
Payment systems
current Medicare, 23–26, 33–34
current shortcomings, 1, 4, 19–20, 25–26, 32, 33–34, 55, 80
effects on provider behavior, 37–38, 46–47
excessive focus on, in health system reform, 53
retrospective, 34
See also Prospective payment
Penalties for lack of improvement, 93–94
Performance improvement
defining, for distribution of incentive rewards, 83–85
payment incentive distribution methodology, 9–10
payment incentive goals, 44
payment system linkage, 2, 17, 22–23, 29, 36–38, 46
recommendations for public reporting, 10–11
relative comparisons, 91
rules for health care process redesign for, 15
strategies for, 18
technical assistance for, 18
Performance measurement
case mix considerations, 129–130
common features of existing pay-for-performance programs, 42–43
of coordination of care, 45
current measurement sets, 86
domains of quality, 9, 21, 51, 81–83
in home health agencies, 216–217
in hospitals, 211
ideal characteristics, 134–135
improving provider participation, 11–12, 116–117
longitudinal measures, 12, 18, 116
pay-for-performance implementation, 6, 11, 103, 107, 108–109, 110–111
for payment system assessment, 2, 17, 23
in post-acute care settings, 148
potential adverse consequences of, 6, 29, 51
provider participation requirements, 112
provider resources for, 114
recent efforts, 20
recommendations for implementation, 17–18
recommendations for improvement, 2, 12
shortcomings of current system, 18, 20–21, 110
in skilled nursing facilities, 219
stakeholder collaborations for, 14
statistical issues, 112, 129–130
structural measures, 90
Performance Measurement: Accelerating Improvement, 2, 17–18, 51, 137–138
Physician Group Practice Demonstration, 38, 69
Physician–patient relationship, 29
Physician Practice Connections, 41
Physicians
distribution of rewards, 118–119
Medicare prospective payment system, 34–35, 149–150
Medicare qualifications, 25
negative perceptions of payment system reform, 52–53
pay-for-performance implementation in private practice, 110
payment incentives as barrier to performance improvement, 29
virtual groups, 119
Population health
international comparison, 19
patterns and trends, 19
significance of Medicare practices, 26
Preferred provider organizations, 41
Premier Hospital Quality Incentive Demonstration, 38
Preventive care
shortcomings of current payment system, 1, 4
shortcomings of Medicare reimbursement, 33
Primary care, 4, 27, 43, 52–53, 73, 120
Priority Areas for National Action: Transforming Health Care Quality, 71
Private sector
in collaborations for performance measurement, 14, 23
cost-shifting outcomes of payment system reform, 53–54
pay-for-performance funding models in, 62
pay-for-performance in executive compensations, 47
recent pay-for-performance experiments, 39–41
Prospective payment, 34–35, 37, 38
for inpatient hospital care, 145–146
for outpatient dialysis services, 148–149
outpatient hospital care, 145–146
for physician services, 149–150
shortcomings of current system, 4, 26
for skilled nursing facilities, 146–147
Public reporting
access to care decreased by, 50
current Medicare efforts, 104–105
distribution of rewards and, 107
pay-for-performance implementation, 5, 10–11, 12, 103–106
quality of care and, 26
Q
Quality Improvement Organizations, 18, 52, 94, 128
Quality of care
ambulatory care performance assessment, 213
consumer spending and, 19
current Medicare payment system and, 4, 25–26, 33–34
dialysis services assessment, 208–209
domains of quality, 9, 21, 51, 95–96
health plan performance assessment, 215
home health agency performance assessment, 217
hospital performance assessment, 211
information technology to improve, 13
Medicare Advantage program, 150–151
Medicare provider qualifications, 25
prospective payment system and, 146
public reporting of provider performance and, 26
recommendations for payment incentive program design, 9, 21–22, 82
See also Performance improvement;
Clinical quality
R
Regional Health Information Organizations, 126
Relative value of medical services, 1, 25–26
Research
long-term funding for payment incentives program, 75
needs of pay-for-performance program, 139–141
oversight, 140
pay-for-performance studies, 3, 36, 46–48
payment incentive implementation, 23
payment system effects on provider behavior, 37–38
performance measurement, 137–139
Retrospective payment system, 34
Risk adjustment, 48–50, 129–130
S
Safety of care
as basis for performance reward, 81
Settings for care
defining comparison groups for reward distribution, 94–95
distribution of rewards, 118–119
funding sources for payment incentive programs, 7, 8
health information technologies for, 125
implementation of pay-for-performance, 11–12, 27, 110–112, 116–117
Medicare prospective payment system, 145–151
Medicare spending, 35
performance measurement and, 11–12, 116–117
size of organizations, 115
Size of reward, 100
Skilled nursing facilities
Medicare payment system effects, 38
Medicare prospective payment system, 34–35, 146–147
pay-for-performance implementation, 111–112, 219
performance measurement, 219
Specialization
implementation of pay-for-performance, 118
patterns, 117
pay-for-performance programs, 43
performance measurement, 117–118
shortcomings of current payment system, 4
Sustainable growth rate, 8, 35, 66, 68, 75, 149
T
Technical assistance for quality improvement, 18
To Err Is Human: Building a Safer Health System, 15
U
Utilization
Medicare patterns and trends, 13, 19, 37, 119
shortcomings of current Medicare payment system, 25–26, 80
specialty care, 117
V