Careful Design, Gradual Implementation Crucial to P4P Success

America must have uniform and universal performance standards that are incrementally implemented if pay-for-performance programs are to succeed, according to Bruce Bagley, M.D., AAFP director for quality improvement.

Bagley made his comments Feb. 8 during the National Pay for Performance Summit here. The summit brought business, the insurance industry, health care institutions and physicians together to discuss the framework on which P4P programs should be built.

Physicians will object to P4P programs if public or private payers move too quickly to implement numerous performance measures, said Bagley. "Physicians want a relatively limited set of measures that can be implemented in the office at the pace of their practices."

Although electronic health records are expected to help ease the administrative burden posed by implementing P4P programs, 70 percent of America's physicians currently use paper charts Bagley told some 700 summit participants during the plenary session, "Setting National Pay for Performance Standards."

Bagley also noted that P4P programs should be designed to enable physicians to gather data about performance measures at the time of the clinical encounter rather then via a retrospective review. Chart reviews, said Bagley, should not occur.

"When you hear 'chart review,' you envision a team of nurses with clipboards headed to the chart room to look at a year's worth of diabetes care," he said. "As you know, that's expensive. It gives poor data and doesn't lead to quality improvement. It tells you where you were last month or last year. That's a dumb idea. Don't do it."

Instead, Bagley urged P4P architects to develop patient encounter formats that provide evidence-based clinical guidelines for a patient's condition and space to note when a performance measure has been met. "We need to put a system in place that gets the measure identified at the time the care is given," said Bagley. "You get better care right then and there" with such a system.