Pay-for-performance programs used by health-insurance companies to reward physicians for adhering to practice guidelines and meeting quality-improvement standards are gaining popularity nationwide. Already, theyre being implemented by the major insurers that contract with health-care professionals here.


P4P programs, as they are called, use specific performance indicators to evaluate providers, and either reimburse them at a higher rate for adhering to those standards or pay them a bonus. Those standardized performance measures, primarily focusing on preventive medicine, are being developed by private health plans, medical associations, and the federal government.


Mountlake Terrace, Wash.-based Premera Blue Cross, which contracts with 3,200 health- care professionals and five hospitals in Spokane County, has a P4P program. Group Health Cooperative, which has about 200 physicians in its network here, also has started one. Walla Walla, Wash.-based Asuris Northwest Health, which offers coverage here, says its developing such a program. The federal government has started a nationwide pilot P4P program for Medicare, and the Everett Clinic, of Everett, Wash., is participating in that trial.


In response to the growing P4P trend among health-care plan providers, the Spokane Regional Chamber of Commerce is heading up a local P4P task force in coordination with the Spokane County Medical Society. That task force is looking at ways to coordinate P4P programs into a single data system that all insurers and providers in Washington state could use.


Health care is headed in this direction, and all physicians will be affected, says Dr. Robert Benedetti, medical director at Rockwood Clinic PS, of Spokane. The message to doctors is, Ignore this at your own peril.


Rockwood Clinic has been participating voluntarily in Premera Blue Cross Quality Incentive Program since it started in 2003, Benedetti says.


In 2002, Premera began working with multi-specialty groups statewide, such as Rockwood Clinic and the Physicians Clinic of Spokane, to decide which areas of health care should be measured and how to establish those measurements, says Scott Forslund, Premeras spokesman. The group used the Health Plan Employer Data and Information Set (HEDIS) as one of its guidelines. HEDIS is a set of standardized performance measures designed to help health-care purchasers and consumers compare the performance of managed health-care plans, and was established by the National Committee for Quality Assurance.


Premera uses whats called a Quality Score Card to evaluate physicians, Forslund says. A few of the preventive-care areas covered in that report include regular breast cancer screenings, diabetes blood tests, and management of ear infections. That annual report evaluates 13 medical groups statewide to track whether physicians meet those standards, and whether their patients are satisfied with the care they receive, he says. They receive scores ranging from zero to 100 in a variety of areas including quality measures and patient-satisfaction measures.


Initially, Premera tracked providers performance, but didnt reward improvements in quality. In 2004, its findings were published, and now both consumers and physicians can access the Quality Score Cards on Premeras Web site. Forslund says consumers should have access to that information to help them make an informed choice.


If you go to buy a car, you go in with Consumer Reports, he says. Most people dont understand that the same kinds of general standards exist for doctors, too.


The company uses claims data to track what it regards as improvements in quality of care, and pays bonuses to providers who make those improvements as part of its Quality Incentive Program. Six medical groups statewide are participating in that program, Forslund says.


Benedetti says Premera doesnt pay higher reimbursements to providers whom it identifies as high quality physicians, but pays bonuses to clinics out of a pool it reserves for those payments. As one of the participating medical groups, Rockwood Clinic puts bonus money it receives into its general budget, rather than distributing the money to its 110 physicians, he says.


The incentive for physicians who participate in P4P programs, however, doesnt primarily come from the bonus money, anyway, Benedetti says.


The amount of money required to get someone to make a fundamental change in the way they practice medicine isnt available in P4P, he says. The incentive is that happy, well-cared-for patients dont sue you as much, and they tell their friends about your practice.


Benedetti adds that financial reimbursement wont drive physicians behavior until a larger amount of their income is based on quality measurements. He believes health care is headed in that direction, and P4P is one of the first steps toward that end.


Rockwood Clinic had established its own in-house quality measures before joining Premeras Quality Incentive Program, and that program has helped the clinic make significant improvements, particularly in the area of patient satisfaction, he says. It has been gathering additional information, through patient surveys and other data, to help it make those improvements.


The Polyclinic, in Seattle, has the highest patient-satisfaction scores of all the program participants, Benedetti says. One of the advantages of making those scores available to the public is that medical groups across the state can collaborate, and even compete, with each other to meet the established standards, he says.


Forslund says the underlying theory behind making sure doctors are providing adequate preventive care is that it will be more cost-effective in the long term to do so, by decreasing emergency room visits and more expensive procedures that eventually would have to be done if a problem isnt addressed early on.


Group Health


Group Health Cooperative uses a tool called the Practitioner Performance Report (PPR) in its P4P program, says Dr. Bob Pope, medical director for the Eastern Washington-North Idaho district of Group Health. That report, which Group Health started four years ago and issues quarterly, measures criteria that include patient satisfaction, antibiotic utilization, and quality of care, Pope says. Other measurements are specific to providers specialties. All of the criteria are based on HEDIS standards, he says.


We have a philosophy that primary care is key to making sure that preventive measures are tended to appropriately, Pope says.


Group Healths network includes both staff and contract physicians. In its contracted network, scores are given to individual providers, and those scores are used in reimbursement rate negotiations with the medical practice as a whole, he says. If the practice has statistically significant performance, then it can receive reimbursements that are above the market rate. Staff physicians, on the other hand, receive a salary, and there is a maximum of 10 percent of their pay that can vary based on PPR scores, he says.


One way Group Health tracks performance is by looking at claims that providers have submitted, and randomly selecting patients to receive a survey in the mail. Pope says that, overall, satisfaction scores have been increasing since Group Health started the program.


Its not a given anymore that if you go to a doctor thats licensed that youll get quality care, he says. Physicians accept that this is happening, and that they provide a service that payers are interested in getting the value that is expected.


Dr. Brian Seppi, vice president of the Spokane County Medical Society, agrees there needs to be more streamlined standards of care that physicians should meet and that should be available to patients.


Right now, you dont know what youre getting, a Cadillac or a Volkswagen, in terms of quality of care, Seppi says. Hopefully, if theres enough transparency, patients can compare practices and direct their health care toward those that do better.


He says buyers of health-care insurance also have a responsibility, however, to participate in wellness programs. If employers include wellness programs in their health plans, then those people can get help evaluating their potential health risks and trying to lower them. Such actions can cut long-term medical costs, he says.


Seppi expects that within the next year or two, most health-plan providers will have adopted some type of P4P program. He says that its going to be a big transition for physicians here, and that many of them are excited about getting paid in proportion to how well they take care of their patients.


I think it will help the transformation of health care, but its just the beginning, Seppi says.


While physicians may look forward to programs that reward quality, theyre also concerned about how the data will be collected, he says.


Were worried that if everyone does their own program, including Medicare, then administratively it will become too much data to collect and will overwhelm practices, he says.


Seppi says that when insurance companies in California began implementing P4P programs a few years ago, the major insurers there agreed to use a single data-collection system. The Spokane chambers task force, along with several other organizations in Washington state, is trying to follow Californias lead and work out a common means of collecting data. That task force is meeting monthly and will publish a research paper next year outlining its findings and recommendations, he says.


Benedetti says that if health-plan providers in Washington dont adopt a common data-collection system, keeping up with the information required by each P4P program will be a big headache for physicians. Rockwood Clinic will implement an electronic-records system next January to collect data and keep track of quality-care measurements, he says. Hospitals and clinics nationwide are going to have to start using similar systems as P4P programs become more prevalent, he adds.


This is a train thats left the station, he says. You can get on it or you can get left behind.