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American Thoracic Society Endorses Pay-for-Performance

March 24, 2010

The ATS has released an official policy statement of pay-for-performance (P4P) in pulmonary, critical care and sleep medicine. In the statement, the Society encourages clinicians in these fields to participate in P4P programs and views them as an opportunity to partner with healthcare payors, accrediting organizations, governmental oversight groups and others to improve quality, rather than as a threat to autonomy and independence.

The statement appears in the April 1 issue of the American Journal of Respiratory and Critical Care Medicine.

“The ATS endorses P4P when such programs explicitly link reimbursement to the quality of healthcare provided,” said former ATS President John E. Heffner, M.D., who co-chaired the writing committee that produced the statement with Jeremy M. Kahn, M.D., M.Sc., who is assistant professor of medicine and epidemiology at the University of Pennsylvania. “Programs provide a promise. If appropriately implemented, they can align payor and provider incentives to improve patient care. Our P4P document is in concert with the overall moral and ethical framework of the ATS. The Society supports public health policies and P4P programs when they are developed with the intent of improving outcomes for patients with lung diseases, sleep conditions and critical care illnesses.”

Healthcare is inextricably linked to the financial interests of its providers. Among the ATS’s primary goals are to improve quality of care for patients and to advance policies that appropriately compensate individuals who provide such care. P4P is one way to couple these two aims.

“Most current systems provide financial incentives to clinicians for providing care based on the patients’ diagnoses, the complexity of work they do and the time they are involved,” explained Dr. Heffner. “P4P offers an alternative and complementary approach that places more emphasis on the outcome, or quality of care, rather than the quantity of patients seen.”

The financial incentives in P4P programs are designed to serve two major purposes: they create an economic stimulus for quality improvement and adoption of evidence-based practices; and they correct the negative consequences of reimbursement schemes that link payment to the volume or complexity of services, rather than the quality.

“The purpose and goals of P4P should be to improve health, reduce disparities, decrease waste and expand access to care,” Dr. Heffner continued. “Without the intention of maintaining or improving quality of care, P4P programs are schemes that would decrease cost alone and therefore represent a misapplication of performance-based reimbursement.”

However, P4P may also create disincentives for healthcare providers to take on complex or difficult cases, particularly where well-known racial, socio-economic or gender disparities in outcomes exist. According to the statement, it could also encourage “patient dumping” or “cream skimming,” as healthcare providers seek to minimize their risk of financial losses or optimize their financial gains.

To reduce the likelihood of such problems arising, the ATS endorses a stratification of performance measurements by high-risk groups, which would specifically target underserved and at-risk populations so as to provide financial rewards for clinicians who care for such vulnerable patients.

“Performance improvement must remain the central tenet of P4P and performance is defined by the degree to which these initiatives promote the delivery of high-quality patient care,” said Dr. Heffner.

Furthermore, he noted, “P4P must never degrade the healthcare team, its interdisciplinary nature, or the autonomy and service orientation of providers, all of which are essential for providing high-quality care. Hospitals and physicians should establish mechanisms to reward nurses, respiratory therapists, pharmacists, nutritionists and other healthcare professionals who might not benefit from rewards to physicians for high performance under existing reimbursement structures.”

The statement also emphasizes that more research must be done on P4P, particularly to evaluate its effectiveness, the organizational, structural and cultural factors that may influence its success, and its ability to increase access to healthcare and improve outcomes. In all cases, the cost-effectiveness of a program must always be monitored.

“P4P programs are likely to expand in the coming years. Indeed, linking reimbursement to quality is a central tenet of the recent healthcare reform measures passed by the United States Congress,” said Dr. Kahn. “Through this statement, the ATS endorses the concept of P4P and offers a framework for its members to work with healthcare administrators and policy makers to develop these programs.”

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