AAP: A P4P primer for pediatricians

Pay-for-performance (P4P) programs may be in their infancy, but they are inevitably coming to a pediatric practice near you, explained Keith Dveirin, MD, at the American Academy of Pediatrics (AAP) 2008 National Conference and Exhibition in Boston.

"For those of you haven't experienced P4P, you will," Dveirin said. "It's coming."

As defined by the Centers for Medicare and Medicaid Services (CMS), P4P programs use payment methods and other incentives to encourage quality improvement and patient-focused high-value care. P4P programs can rate physicians using clinical outcomes, utilization management, administration practices, patient satisfaction, and the cost of medical care.

Some of the motivations behind instituting P4P programs include variability in medical practices, failure to follow best practices, increase and variability of the cost of medical care, desire for accountability on the part of those paying for health care, and a push for quality improvement, Dveirin stated. Sponsors of P4P programs include large employers, Medicare, Medicaid, and health insurance plans, such as those run by UnitedHealth, which implemented a P4P program in Dveirin's practice.

While the American Medical Association, the Joint Commission on the Accreditation of Healthcare Organizations, and the American Academy of Family Physicians all have defined principles for P4P programs, the AAP so far has addressed this topic via a policy statement in February 2008. Dr. Dveirin pointed out that P4P programs primarily target adult services, which account for 80% to 90% of payer expenses. Pediatric P4P programs, therefore, are mostly an afterthought, explained Dveirin.

However, pediatric performance measures for P4P programs are in existence; CMS has developed some, Dveirin said. They include childhood and adolescent immunization status, appropriate testing for children with pharyngitis, appropriate treatment for children with URI, follow-up for children prescribed ADHD medication, and use of appropriate medications for children with asthma.

The AAP met with United Health in January 2008 to refine UnitedHealth's pediatric P4P performance measures and other aspects of its program. Performance measures should be valid, reliable, based on national standards, evidence-based when possible, risk-adjusted when appropriate, and developed collaboratively with physician input. A retrospective review of 24 months of administrative claims data found that only 19 out of 1,783 episodes of care (1%) were counted for quality analysis, and only 19 out of 263 (7%) episodes of acute otitis media, acute sinusitus, asthma, and pharyngitis that were analyzed for cost were evaluated for quality of care.

"I think UnitedHealth is more of a cost program than a quality program," said Dveirin. "It's not ready for prime time yet."

Dveirin recommended that the AAP develop a quality improvement model for P4P. Rather than wait until all the performance measures are considered good enough, he recommended using the best measures available now, then make ongoing modifications.