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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
No Free Lunch
The Juice Can Be Worth The Squeeze
What Price Quality?
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Samuel W. Warburton, MD, durham, usa Professor and Chief, Division of Family Medicine, Duke University Medical Center
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As the Halladay article points out, there is no free lunch. Quality and performance data collection is an expensive endeavor, especially for small or solo practices. The solution seems too easy. Practices need to be organized into networks around hospitals and referal institutions. And those benefitting institutions, in turn, provide the IT resources to link the practices, compile the quality and performance data and submit to the 3rd party payors. Our practice participates in a pay-for-performance plan not reported in the article. This plan focuses on diabetes, cardiovascular disease and health maintenence. After thresholds that are modeled on NCQA's HEDIS metrics are met, the practice can earn additional dollars. On a base of 3000 patients in this plan, our practice has earned $25-40,000 yearly for the last several years. While the administrative burden is considerable, so is the reward. I constrast this to the minimal 1.5% 'reward' from CMS for reporting PQRI. Competing interests: None declared |
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Francois de Brantes, Newtown, United States CEO, Bridges To Excellence
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The authors point out an important component of pay-for-performance initiatives that is consistent with our own research published earlier this year (1). In economic terms, the principle is that of cost to benefit of an enterprise engaging in any business activity. In laymen terms, the juice has to be worth the squeeze. This is a point that cuts both ways, for the payer as well as the provider. The current focus of many quality reporting and improvement efforts tend to be on measures that have only a distant relationship to lowering cost or improving patient outcomes. As a result, the amounts that payers are willing to offer as a benefit to a practice for participating in the effort are relatively small, and this level of benefit is often lower than the cost of participation for the practice. Our focus with Blue Cross and Blue Shield of North Carolina in the implementation of the Bridges To Excellence effort was to encourage the reporting of measures that have a significant impact on patient costs and outcomes and thus warranted the provision of significant incentives. Practice A’s benefit of participating in the BCBSNC/BTE program exceeded $100,000 over two years while the cost to participate (most of it non-recurring) was less than half that amount. Clearly an opportunity to double your money will encourage almost all practices to participate in a quality improvement effort. At that level of return, the juice is absolutely worth the squeeze. The ingredients to ensure success for both payer and provider in a quality reporting and improvement program are simple: know your costs and understand your benefits. And Practice A’s experience is by no means unique as there are a large number of practices in North Carolina and other states that have reaped similar rewards. As importantly, so have the payers. (1) de Brantes F, D’Andrea G, “Physicians Respond to Pay-for- Performance Incentives: Larger Incentives Yield Greater Participation”, AJMC 15: 305- 310 May 2009, Number 5. Competing interests: None declared |
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Bruce Bagley, Leawood, KS USA Medical Director for Quality Improvement
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The Cost of Quality-
The article by Halladay et al attempts to determine the cost of recording and reporting quality data. The amount of variation in the various practices and programs makes it difficult to draw many conclusions about the actual cost.
Family physicians and their care teams should want to have this information in front of them when making decisions about diagnosis, treatment and follow up for patients. We should not be asking physicians to collect data that is not pertinent to the patient care. If the cost of organizing that information in a systematic way is balanced against the increased efficiency of the physician-patient encounter, it should be a clear win for all.
Registries for the few common chronic illnesses will soon be the standard of care because they allow and promote proactive management. Data in the registry can be easily exported for quality reporting purposes. In addition, this data can serve as the foundation for quality improvement efforts.
With these systems in place, the office runs better and the patients get better care. If someone comes along looking for quality data in exchange for financial incentives or if a health plan challenges your quality of care, you will be ready with solid evidence. In addition, if you are using the data for quality improvement, when you are measured, you will be a high performer regardless of the method used. There may be a cost to doing the right thing for patients and in this case it is money well spent.
Bruce Bagley, M.D.
Competing interests: None declared |
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