Pay for Performance: Go for the Gold

Melissa Brown, CPC, CPC-I, CFPC, RHIA 

As I watched the summer Olympics this past August, I couldn’t help but think about the correlation to the trend for “pay for performance,” or P4P, we face in health care. The Olympians used various approaches to prepare themselves for the Olympics, but they all had one goal in mind: Gold. In contrast, providers who take a “wait and see” approach toward P4P programs are sure to miss the starting gun.

P4P Is Here to Stay

Several years ago, the Centers for Medicare & Medicaid Services (CMS) introduced the concept of paying for quality services, with the promise of better reimbursement for physicians who reported certain quality measure indicators. The Physician Quality Reporting Initiative (PQRI), which has since become the Physician Quality Reporting System (PQRS), set the stage for a payment system based on quality performance. The goal from the onset has always been to improve patient care and provide better value (quality) for the money being spent on health care (a.k.a., value-based purchasing).

Anyone who has read the latest final rules for various Medicare payment systems can see that P4P is fast approaching (I would argue it’s already here). The proposed changes and overlapping goals of PQRS, the CMS Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, and the Electronic Prescribing (eRx) Incentive Program make it clear that CMS is intent on rewarding providers who are on board and penalizing those who aren’t. And the trend is contagious: A scan of the headlines in health care journals reveals that many private payers are also implementing P4P-based incentive programs.

Patient-Centered Medical Home Is Within Range

Another concept you’re sure to hear more about in the coming years is the Patient Centered Medical Home (PCMH) designation, introduced by the National Committee for Quality Assurance (NCQA). The NCQA website describes the PCMH as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.” Such medical homes seek to improve patient outcomes by strengthening patient-clinician relationships so clinicians can efficiently deliver the right health care at the right time.

In this Game: Quality vs. Quantity

When looking at these emerging trends, some may claim we are recycling the concept of managed care. Although the basic concepts may be similar, the key difference for these new quality concepts is found in the incentives. The biggest argument against managed care was the perception that patients were denied care due to financial incentives for saving costs. The incentives being introduced now (and just as importantly, the penalties) are tied to the quality of the care, not the volume.

The gold medal winners in these games will be the enterprising providers who started training early, or who are training hard now. These providers are looking to maximize efficiencies among the available programs, and keeping their focus on the true goal: favorable patient outcomes.

Whatever your opinion of P4P programs, they are a reality in our industry, and only those who make the transition from simple data collection to ensuring quality outcomes will go home with the gold.

Melissa Brown, CPC, CPC-I, CFPC, RHIA, is manager of reimbursement and quality improvement, University of Florida Jacksonville Physicians, Inc. She has 20 years of experience in the health care industry. Ms. Brown’s areas of expertise include fee analysis, budgeting, and PQRS. She enjoys presenting on teamwork and communication skills. Toastmasters International awarded her its highest honor, Distinguished Toastmaster (DTM). Ms. Brown served as co-director of the annual “Coding on the River” conference in Jacksonville, Fla. for several years and is a past-chair of the AAPCCA board of directors.


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