Correspondence
Pay for Performance in Commercial HMOs
N Engl J Med 2007; 356:872-873February 22, 2007
- Article
To the Editor:
In their discussion of pay for performance, Rosenthal et al. (Nov. 2 issue)1 set up a troubling implication regarding attribution of performance for patients who are cared for by multiple physicians. They imply that such attribution is more feasible when patients have a designated primary care physician. Yet is it reasonable to hold primary care physicians accountable for care provided by others?
Primary care physicians had the misfortune of being gatekeepers in the 1990s, a role that did not enhance the attractiveness of general practice. Will they now become the street sweepers in the new realm of pay for performance? As a primary care physician, I do not relish having my individual report card determined by the behavior of other physicians, nor do I willingly accept the burden of monitoring other physicians' professional decision making.
Since the quality of care is mostly related to systems organization at the enterprise level, the main focus of quality measurement should also be at the enterprise level. Attributing the performance of complex systems to individual primary care physicians is a misdirected solution to the challenges of value-based reimbursement.
1 ReferencesChristine A. Sinsky, M.D.
Medical Associates Clinic and Health Plans, Dubuque, IA 52001
csinsky1@mahealthcare.com 1
Rosenthal MB ,Landon BE ,Normand SL ,Frank RG ,Epstein AM . Pay for performance in commercial HMOs. N Engl J Med 2006;355:1895-1902
Full Text | Web of Science | Medline
To the Editor:
Although Rosenthal et al. suggest possible barriers to implementing pay for performance beyond traditional health maintenance organizations (HMOs), we believe these concerns are overstated. UnitedHealthcare is operating a national program for performance transparency and improvement (UnitedHealth Premium) that provides both consumers and physicians with information on the performance of physicians according to criteria for quality and efficiency of care, using national evidence-based and consensus standards. This program, which is available to employers and consumers to help inform care choices, is a platform for implementing a pay-for-performance program that is administratively straightforward and efficient. In our pilot pay-for-performance program (UnitedHealth Practice Rewards), physicians can receive automated fee-schedule enhancements on the basis of high levels of performance in the domains of clinical quality, risk-adjusted episode efficiency, and administrative efficiency. This pay-for-performance program operates with no administrative burden to physicians' practices and operates across products, using data from UnitedHealthcare's commercial population. As such, it is a model applicable both to preferred-provider organizations (PPOs) and consumer-directed health plans in the commercial marketplace and to public programs, such as the traditional Medicare program.
Lewis G. Sandy, M.D.
Michael Ile, J.D.
UnitedHealthcare, Edina, MN 55436
lewis_g_sandy@uhc.com Dr. Sandy and Mr. Ile report having equity ownership and stock options in UnitedHealth Group, the parent company of UnitedHealthcare.
Author/Editor Response
We observed that health plans that use capitation or gatekeeping arrangements are at a natural advantage with regard to identifying accountable physicians for the purpose of pay for performance. This was not a value judgment but instead was a reflection of the fact that under those arrangements there is prospective assignment of a population of patients to either groups or individual physicians. Whether such assignment is appropriate for the purpose of rewarding high-quality care will depend on the circumstances, including the quality measures to be examined. For example, in some of the capitated arrangements in which pay for performance is being used, the accountable entity is a multispecialty medical group, and the measures being evaluated are largely focused on appropriate prevention and management of chronic conditions, most of which are comfortably within the domain of primary care. However, since many physicians do not practice in integrated groups, it may be fruitful to consider whether well-designed financial incentives can encourage the coordination of care among unaffiliated providers.
Although we found fewer pay-for-performance programs among health plans that did not rely heavily on capitated and gatekeeping arrangements, we acknowledge the point made by Sandy and Ile. A number of notable examples suggest that the barriers to implementing a pay-for-performance program are not insurmountable in these settings. In addition, the notion of attaching a single pay-for-performance program to all of a payer's products, as Sandy and Ile describe, is appealing both because of the advantage of larger patient populations with this approach to measurement and because of its simplicity from a provider's perspective.
Nonetheless, the question of whether physicians have the ability to undertake population health management when patients are not required to select a medical group, care system, or primary care physician remains at least a theoretical concern, even when retrospective assignment makes pay for performance possible in a PPO or a consumer-directed health plan. UnitedHealthcare's pilot program may offer an opportunity to learn about how these issues play out in practice. Such an understanding will be critical for determining the ultimate effect of pay for performance, since the majority of persons enrolled in private insurance plans and the majority of those enrolled in Medicare have non-HMO coverage.
Meredith B. Rosenthal, Ph.D.
Harvard School of Public Health, Boston, MA 02115Bruce E. Landon, M.D., M.B.A.
Harvard Medical School, Boston, MA 02115Arnold M. Epstein, M.D.
Harvard School of Public Health, Boston, MA 02115- Citing Articles (2)
Citing Articles
1
J. Graham Atkinson, Kathleen E. Masiulis, Len Felgner, Dale N. Schumacher. (2010) Provider-Initiated Pay-for-Performance in a Clinically Integrated Hospital Network. Journal for Healthcare Quality 32:1, 42-50
CrossRef2
Richard A. Hirth, Marc N. Turenne, John R.C. Wheeler, Qing Pan, Yu Ma, Joseph M. Messana. (2009) Provider Monitoring and Pay-for-Performance When Multiple Providers Affect Outcomes: An Application to Renal Dialysis. Health Services Research 44:5p1, 1585-1602
CrossRef
