Time is short to shape pay-for-performance

Pediatricians are running out of time to influence pay-for-performance measures that are set to transform health-care delivery. The future is not entirely bleak, said Paul Miles, MD, vice president and director of quality for the American Board of Pediatrics at the PAS Annual Meeting today, but the profession must act now if pediatricians are to shape the solution and not be shaped by it.

"The mode of financing has a key impact on how health care is delivered," Dr. Miles told the AAP Presidential Plenary. "The problem is that pay-for-performance is not argued or conceived on a scientific basis. No one is sure what role financing plays in physician performance, decisions, or quality."

There are more than 100 pay-for-performance experiments underway across the country, he continued. The only common ground they share is the observation that payment systems in place today often act to impair the delivery of quality care, especially in areas such as chronic care and preventative care. There is not even a common understanding of the goals of pay-for-performance.

"The ultimate in quality is appropriate pediatric care for every child. But nobody is advocating paying whatever it takes to give every child access to a pediatrician," Dr. Miles noted. "We are really talking about some combination of quality and cost."

Other common confusions include whether quality should measure the process of care or the outcome of care; whether to make incentives competitive or to reward all practitioners who exceed specific goals; and whether it is even possible to increase quality without also increasing expenditures.

Many pay-for-performance programs portray more effective care as the primary goal, but incentives actually reward more efficient care. Some programs reward increased safety, a few reward more timely care, and still others reward more patient-centered care. All of these represent different dimensions of quality, Dr. Miles said, but there is little consensus as to which dimensions are more important.

"There is some evidence that pay-for-performance has some impact," he said. "But it is not the next best thing that is going to transform health care. And pay-for-performance is what is going to happen, either with us or to us."

Fortunately, he added, pay-for-performance in the pediatric world is one to two years behind similar programs in adult care. That gives the pediatric community time to influence programs that eventually emerge from the federal government and private payers.

The most effective programs appear to be those that incorporate infrastructure investments such as electronic medical records and benchmark goals as well as incentive payments. A two-year study in pediatric asthma care at Cincinnati Children's Hospital Medical Center, for example, produced what Dr. Miles called amazing results.

The keys, he said, were infrastructure investments, network-wide; practice goals; and benchmark targets taken from the literature. The goal for influenza vaccination, for example, was 40%, which is the top end of practice from the current literature. The study population of more than 300 pediatricians in 44 practices with 12,000 patients hit 55%.

Overall performance was even stronger. At the start of the study, just 3% of patients were receiving "perfect" care as defined by a set of evidence-based performance measures. Two years later, 83% of patients were getting perfect care.

Even federally-funded programs can produce significant increases in the quality of care, Dr. Miles noted. Between 1993 and 2002, the percentage of renal dialysis patients covered by Medicare receiving quality care increased from 46% to 87%. Over the same period, significant differences in the quality of care based on patient race all but disappeared. They key to success, he said, was pegging quality incentives to improvements across the entire network, not to individual performance.

"We need to build on examples that we know work," Dr. Miles concluded. "If you create the infrastructure, physicians will do the right thing. Pediatricians want to provide quality care, but money can be a significant barrier."