Patient Flow Enewsletter
Volume 2, Issue 5
Wednesday, October 5, 2005
Giving incentives for outstanding performance at work is not a new concept. Businesses have been using this strategy for years, rewarding hard work, dedication, and other measures of performance in their employees with financial bonuses. However, for the medical field, this concept is just emerging in hospitals and emergency departments amid a flood of different opinions from medical professionals.
The P4P Concept
Although there are several definitions of P4P, in this article, I define it as "tying incentives to productivity of the provider." In recent years, policy-makers have focused their attention on P4P programs in hopes of improving the quality of health care delivered by providers.
Ten years ago, pay for performance was seen in very few places. Now more than not, hospitals are using some sort of hybrid of this system. This is especially a new concept for ED doctors. They used to be on an hourly rate, but now instead of per hour, they may be paid per patient seen or procedure performed.
In most P4P systems, productivity is measured by the number of patients seen per hour by a provider. Incentives are a percentage of a provider's billings. Some systems are 100 percent pay for productivity, and others use a combination of an hourly rate and measures of productivity. However, if the level of incentive is not enough to move the train, then doctors will figure out where the happy medium is. The P4P model really works best when it's 100 percent pay for productivity.
In a place like the ED, where patient throughput is often the focus, P4P can be especially beneficial. If you look at the Urgent Matters flow chart, patient throughput in the ED is primarily dependent on physicians. In the P4P model, performance and productivity equal speed - doctors are given incentives for performance, therefore improving patient throughput.
The P4P and Quality of Care
One of the reasons P4P models tend to be criticized is because of concerns with quality of care. Critics often think that doctors will get hasty in their care, and will become more motivated by money than patient care. Critics also say that P4P models give incentives to order more lab work and radiology studies, which encourage doctors to order unnecessary tests.
| In response, these criticisms are unfounded. There are two good reasons why these things do not happen: Ninety-nine percent of the doctors in this world are good doctors and won't jeopardize the system. If you look at the difference between incentives for ordering extra tests versus moving more patients through, it is more advantageous to move patients through than to gain higher acuity. Typically, doctors who are attracted to the P4P model are hungry to learn, practice more efficiently and embrace the model of reward for hard work. This model attracts good doctors. |
The challenge is to come up with quantifiable measures of quality of care, rather than simple productivity measured in number of patients seen. The Joint Commission on Accreditation of Healthcare Organizations has measurements of quality, but it is difficult to measure for P4P. Government and private payers are working on measurable variables to look at quality, but we need to move to an outcome measurement system.
The Implementation
For EDs considering P4P, measurement, physician trust and accurate data gathering can be challenging. Implementing P4P in an ED takes a relatively advanced computer system to track and measure billings by doctors and cannot be implemented successfully overnight. A system must be able to track precisely what physicians are seeing by physician and procedure type or the benefits of the model can go awry.
An ED needs adequate volume to implement P4P. An ED that sees any less than 25,000 patients per year will not have an easy time implementing this because doctors will not make any money. There is a threshold.
P4P is a good solution for throughput and patient flow and is a way to improve quality of care. I have seen data that shows physicians increase productivity by 25 to 75 percent when P4P is in place. Speed affects quality because it decreases waiting time, which in the ED means a decrease in patients leaving without treatment (LWOT).
Additionally, P4P motivates ED physicians to perform many of the procedures they have been trained to do, not summoning the specialist in every case. This also improves quality of care as procedures (e.g. closed joint reductions) are done expediently. Perhaps most importantly, physicians reimbursed equitably for their services tend to be more content in their jobs, which certainly trickles down into quality of care and improved patient satisfaction.
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Christopher Krubert, M.D., M.B.A.
Physician Partner of Clinical Operations
ApolloMD Physician Services
