Participating in pay-for-performance (P4P) programs can work out well for both provider and payer. By "performing well" on certain clinical and administrative measures, savings are created that can be shared with both parties. That is, if providers can meet specific metrics that appear to produce some savings by, say, coordinating patient care better or ensuring that the population is receiving timely preventive care, then everyone wins and costs go down.
However, it can be a little perilous to participate in these programs if you don't have a good understanding of your own data. Signing up to meet specific goals without first knowing where you currently stand or without being able to monitor progress as you go along a defined time period can mean falling short of expectations and losing out on additional revenues. So, it is vital that you must be able to run reports in your own system to either validate or dispute the data that the payer will be producing, in terms of how your providers have performed. Depending on your IT infrastructure, this may or may not be an easy task!
What are P4P programs anyway?
Many P4P programs are based on meeting some defined metrics such as percentage of generic versus brand drugs prescribed, or using measures such as those created by the Healthcare Effectiveness Data and Information Set (HEDIS). For example, you may be able to receive a bonus payment if, say, a certain percentage of your patient population receives mammograms within a certain timeframe. Why? Well, by catching breast cancer early it not only saves lives but also saves cost in the system. So if you do a good job on the preventive health side of things then the payer has a vested interest in paying you more to do so.
Some of the P4P models that we currently see are based around more than HEDIS type measures. These are typically homegrown measures (specifically for the Blues companies that are targeting specific chronic conditions) and items that are directly linked to short-term cost such as lowering utilization of ER services, not prescribing brand drugs when there are generics available, achieving certain targets with regard to coordinating care of certain conditions, as well as paying those providers that achieve recognition in programs such as NCQA's Patient-Centered Medical Home.
Why is knowing your data so important?
Payers typically use claims data to gauge your performance in these programs and not everything is accurately captured in those datasets. Additionally, you don't want to be in a situation where each period you do not know how you are going to perform. For example, if you have a provider in your group that may not be great at coding and billing out for every service, then those services are not going to show up in the payer's claim data. If you miss the target, you miss getting the bonus. So knowing what data payers will use to identify how you are performing, and making sure that you can adequately track that data to pick up on poor performance early and often, can make the difference between controlling your outcomes and improving your revenues, or not.
What do I do if I can't track data well?
Many software solutions — known as clinical data analytics software — can help you to "extract" data from EHR and practice management systems for purposes of assessing how providers are performing on designated programs. One such company that works with smaller clients (such as practices rather than just larger clients like hospital systems) is Clinigence. But you may also be able to take advantage of data programs available through local hospital systems that may be using health information exchange systems that you are already feeding data into.
Alternatively, you can track data in a number of less sophisticated ways. For example, simple reporting on visits with certain diagnoses and procedure codes can help determine what percentage of your population you are managing well or need to improve upon. Many e-prescribing systems have reporting modules that can show which providers are prescribing what medications. And if you are currently reporting data to CMS under the Physician Quality Reporting System program, you may already have some good data processes in place that could be used for other P4P programs.
Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She is also COO, National Breastfeeding Center, and cofounder, Patient Centered Solutions. She can be reached at [email protected] or by visiting www.theverdengroup.com.