Scrutinize P4P Programs, Delegates Tell Academy

By Leslie Champlin • AAFP Assembly, Washington, D.C.
10/9/2006

All aspects of pay for performance, or P4P, will come under the AAFP microscope as a result of a resolution passed by the Academy's Congress of Delegates on Sept. 27 in Washington, D.C.

The resolution calls on the Academy to "continue to study and monitor the evolving payment environment in regard to pay for performance programs," with particular attention to seven areas:

patient factors, such as compliance and socioeconomic status;
the relative importance of structure, process and outcomes measures when designing incentive programs;
incentives that cover or exceed the costs of meeting data collection and reporting requirements;
mechanisms that allow physicians to exclude certain patients from P4P consideration for medical, patient or system reasons;
targets, benchmarks or thresholds that encourage both high performance and improvement in the current level of performance;
drug formulary issues that may impede physicians' ability to meet optimal performance on specific patients' outcomes; and
the potential effect that performance measures may have on the doctor-patient relationship.

"There's no doubt that P4P is here, but we need to make sure we don't walk away from our core values," said Ohio delegate Ken Bertka, M.D., of Holland during the committee hearing.

Moreover, basing P4P incentives only on process measures will eventually fail because businesses will demand patient outcomes measures in the health plans they provide to employees, according to Washington delegate Bertha Safford, M.D., of Ferndale.

Outcomes measures, she said, are not to be feared, adding her 49-member practice participated in a model P4P program and improved both outcomes and patient relationships.

"We found that when we were required to improve outcomes, it changed our relationship with our patients for the better," Safford told reference committee participants. "Of our 2,700 diabetic patients, we now have 90 percent compliance with A1c's."

The key, she said, is identifying appropriate goals by which outcomes are measured.

"Be careful about what you choose as a goal," Safford advised. "You'll never achieve 100 percent. It's more important to negotiate the outcomes targets rather than whether to have outcomes measures."

Commission on Quality member Brian Bachelder, M.D., of Mount Gilead, Ohio, agreed. "I'm a group of one, and this can be done by individuals as well as groups," he said of meeting P4P reporting and outcomes measures. "But evaluate the P4P contract carefully" to ensure it defines outcomes measures according to improvement.

That means establishing reachable thresholds, according to Minnesota alternate delegate Keith Stetler, M.D., of St. Peter. "If your patient has an A1c of 10 and the goal is to get it to nine, you meet your threshold when the patient meets that goal."

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