Changes in payment are "absolutely critical," said Dr. Anthony Shih, assistant vice president for quality improvement and efficiency at the Commonwealth Fund, a foundation that studies health issues. Paying doctors for the number of exams or procedures they perform, rather than how well they perform them, he said, results in a care system with "high volume but variable quality," in which doctors are not compensated for making efforts to keep patients healthy.
So far, Shih said, most of the programs are so new that there aren't definitive studies of whether they reduce costs or improve quality.
"CareFirst is somewhat typical of the programs that are emerging, essentially layering incentives on the fee-for-service system," Shih said. "We question whether that's enough, or whether we need more fundamental reform."
It's also not clear whether the extra pay, typically between 2 percent and 8 percent above the standard payment, is enough incentive for doctors to take the extra steps needed to qualify, said Hildy Shaman, director of health industries for PricewaterhouseCoopers, who directed a study of such plans published in August.
Another problem: "They change the programs every year, and by the time you see the outcomes, the plan has changed," Shaman said.
But Francois de Brantes, chief executive officer of Bridges to Excellence, an organization started by employers to promote changes in doctor and hospital reimbursement, said studies now being reviewed by medical journals for publication in the next several months will show that with well-designed incentives, doctors and hospitals "absolutely deliver quality care and are more efficient."
The efficiency, he said, is enough to pay for the costs of the bonuses, making the system no more costly overall. He added that most of the pressure for payment reform has come from employers, who are looking to keep their work force healthy and hold down medical costs.
His organization endorsed CareFirst's effort - the first P4P program in the country to win that designation. He said the designation program was just beginning, and that a "handful" of other programs would be recognized next month.
As programs have become more widespread, physician groups, who initially opposed them, have begun to try to shape them, said Shaman of PricewaterhouseCoopers. "There was a period of time when there was a lot of resistance, but those days are gone," she said. "They may not love it, but this is reality."
