Pay for Performance: What’s Next?

Dr. Roberson identifies small practice size and a limited number of cases on which to base P4P as major problems. Reviewing 10 charts with the same diagnosis, an exercise he has done many times, shows P4P challenges: poor documentation, major decisions made in hospital hallways that go unrecorded, reams of tests not followed up on, and minimal documentation of informed-consent discussions. “For most physician practices, there’s not much strategic thinking about reviewing the work product or building in QI processes,” adds Dr. Roberson.

A critical issue for otolaryngologists and head and neck surgeons is what will be measured. For pediatric specialists, Dr. Roberson conjectures that surgical management of otitis media and of obstructive sleep apnea and tonsillitis are likely P4P targets. With pay and professional reputations on the line, reviewing 150 to 200 charts rather than 10 will be necessary. “Measuring outcomes and rewarding physicians for meeting quality outcomes is a huge culture shift, but without measurement things won’t get better,” he says. That said, payers need to pick clear-cut measures that specialists agree on and that make a difference in the quality of patient care.

David Cognetti, MD, and David Reiter, MD, DMD, MBA, outlining what P4P will mean to otolaryngologists, point out that in the 1990s rewarding and even measuring quality fell by the wayside as “physicians allowed themselves to become commoditized, differentiated from each other only by their cost. Forced to increase patient flow to maintain revenues, physicians were hard pressed to explore quality improvement in their practices.”3 Now, P4P is gaining traction as a way to improve care quality and control costs. Drs. Cognetti and Reiter claim, though, that P4P may have unintended consequences: Basing incentives on patient compliance could encourage physicians to avoid caring for noncompliant patients, doctors may avoid complicated cases, reporting requirements could raise a practice’s information technology (IT) costs, and small groups may not have large enough sample sizes to meet insurers’ performance criteria.

The Right Measures

P4P’s implications for specialists are murky, as most of the 26 current measures apply to primary care. Only three—documentation of tobacco use, smoking cessation advice, and streptococcal testing for children with pharyngitis—are directly applicable to otolaryngology. Skepticism among this specialty runs high; a recent Internet poll of the American Academy of Otolaryngology–Head and Neck Surgery showed that 97% of respondents did not think it was possible for health plans to have the kind of information to accurately identify which physicians meet quality standards.