OECD/WHO/EOHSP report on P4P

OECD, WHO
October 6, 2014

European Observatory of Health Systems and Policies

Paying for Performance in Health Care
Implications for Health System Performance and Accountability
Edited by Cheryl Cashin, Y-Ling Chi, Peter C. Smith, Michael Borowitz
and Sarah Thomson

Forward from the OECD (excerpts):

The problem is that not enough is known about whether and how P4P
actually increases value for money in health systems. The evidence that
P4P improves health outcomes, or even quality of processes of care, is
limited at best.

(This) volume analyses the experience of P4P programmes in 10 OECD
countries, selected to reflect the wide range of health system contexts
and challenges across the OECD.

The findings of the volume in many ways mirror the findings of the few
rigorous systematic reviews of P4P programmes, and the opinions of many
leading commentators. Pay for performance does not lead to
"breakthrough" quality improvements, and performance measures and other
key building blocks of P4P programmes remain highly inadequate.

This volume will not provide answers to questions such as whether or not
P4P works, which performance measures are most appropriate, or what is
the right level of financial incentive to get results. Instead - and
more importantly for real health financing policy in complicated
contexts - are the insights about how P4P might be used to strengthen
health system governance and strategic health purchasing to continue the
shift taking place in many countries from paying for performance to
paying for value.

Mark Pearson, Head of Health Division
Directorate of Employment, Labour and Social Affairs
Organisation for Economic Co-operation and Development


Chapter thirteen:

United States: California integrated healthcare association physician
incentive programme
By Meredith Rosenthal

One of the first, and perhaps the largest, private pay for performance
(P4P) initiatives of this era was launched by the Integrated Healthcare
Association (IHA) in 2001 with eight health plans representing ten
million members in California. The IHA programme is of particular
interest not only because of its size, but also because it has been
sustained for more than a decade and has been independently evaluated.

Results of the programme:

Performance related to specific indicators

More generally, IHA's own monitoring reports give a mixed picture of
performance improvement over time. Performance measures included in the
IHA P4P programme have improved modestly and unevenly across measures,
with no evidence of "breakthroughs" in quality improvement.

Programme monitoring and evaluation

Two controlled studies provide the strongest evidence of impact of the
IHA initiative. These studies find that not all targeted clinical
process measures of quality improved. Among the measures that could be
analysed, only cervical cancer screening improved differentially among
the IHA participants, and improvement was modest at best.

Equity

While there has been no systemic analysis of the impact of the IHA
programme on equity, several empirical clues suggest that P4P may not
have distributed its benefits equally… (I)interviews with physician
group leaders revealed some concerns that the P4P programme has caused
groups to avoid patients whose health of health behaviour would
negatively affect the group's performance.

Cost and savings

While no formal analyses have been reported, it is unlikely that
improvements in clinical quality, health information technology, and
patient experience (to the extent they have occurred) would generate
saving for payers.

From the Conclusions

Another possible explanation for the weak results may be the continued
expansion of the measure set and the difficulty physician organizations
face in making investments in quality improvement when the targets are
continuously moving. There is an obvious tension here with the desire to
include a comprehensive set of measures to avoid "teaching to the test,"
a narrow focus that causes providers to concentrate on a small subset of
tasks at the expense of unrewarded domains, and to incorporate the best
available measurement science over time.

http://www.oecd-ilibrary.org/content/book/9789264224568-en

****

JAMA
November 6, 2014
Designing Smarter Pay-for-Performance Programs
By Aaron McKethan, PhD; Ashish K. Jha, MD, MPH

The idea behind pay for performance is simple. Because individuals and
organizations respond to incentives, physicians whose patients achieve
desirable outcomes should be paid more as an incentive to improve their
performance. Yet the results of pay-for-performance programs have been
largely disappointing. One argument is that neither the right set of
incentives nor the right set of metrics has been identified. Another
explanation, which has received far less attention, is that the right
set of patients has not been identified for targeted efforts.

To the extent that higher-risk patients can be reliably identified
prospectively, this information can inform the design of smarter, more
targeted pay-for-performance programs. Specifically, a targeted
pay-for-performance program would have, at its core, a prediction model
that would identify patients who are at elevated risk of failing to meet
a meaningful clinical goal or of having a bad outcome. Predictive models
are not just risk-adjustment models already in use by payers to create a
level playing field. Predictive models can take into account any factor
that is likely to affect a patient's chance of a poor outcome.

There is little doubt that the effectiveness of these programs will be
driven, in large part, by the ability to prospectively identify at-risk
patients. However, given the failure of recent efforts to meaningfully
improve outcomes, testing targeted pay for performance may be worth the
effort.

http://jama.jamanetwork.com/article.aspx?articleID=1934599

****


Comment by Don McCanne

Pay for performance (P4P) continues to be promoted as a means of
improving quality while reducing costs. This 338 page OECD/WHO report
adds to the abundance of the policy literature that shows that P4P does
not achieve these goals, and may actually impair equity.

The policy community never gives up on a bad idea. In this JAMA article
(access is free), McKethan and Jha suggest that we improve P4P by
applying it only to prospectively-identified at-risk patients. Not only
would that be a good study, but it could also result in P4P rewards that
are five times the current levels. What? Greatly increase the complexity
and uncertainty by testing only at-risk patients, if you could even
identify them? And then depend on provider greed to drive the program?
Come on!

One thoroughly tested model that would greatly reduce wasteful spending
while improving quality by redirecting the savings to more appropriate
care is the single payer model - a national health program. We can let
the policy people go out in the alley and play their P4P games while we
get serious about improving Medicare and providing it to everyone.

What the election means for reform, especially single payer

New Republic
November 4, 2014
This Is How the New GOP Senate Will Try to Dismantle Obamacare
By Jonathan Cohn

Most Republicans know that they can't repeal Obamacare anymore. They'll
start with a symbolic vote for outright repeal. From there, (Ted) Cruz
says, Republicans will go after Obamacare provisions "one at a time."

Here's what the GOP has in mind, based on conversations with health care
experts and lobbyists:

Repealing the individual mandate

Repealing or modifying the employer mandate
changing the threshold to 40 hours
could propose raising (50 employee requirement) to 100 full-time
employees

Eliminating "risk corridors"

Repealing the device tax

Abolishing the Independent Payment Advisory Board (IPAB)

Introducing "Copper Plans"
50 percent actuarial value

http://www.newrepublic.com/article/120125/republican-plans-obamacare-device-tax-mandates-risk-corridors

****


Comment by Don McCanne

New Republic's Senior Editor Jonathan Cohn, an astute and very
well-informed observer of the health care reform scene, provides us with
a quite plausible response of the new Republican majority in the next
session of Congress. They will likely fulfill their promise to introduce
legislation to repeal the Affordable Care Act (ACA), though knowing that
the effort will end with either a filibuster or a presidential veto. The
real action will take place over individual provisions of ACA.

Some of the less objectionable measures they propose could be included
in other bills as part of the legislative compromise process. Other less
desirable changes could avoid filibuster by being tacked onto
reconciliation bills, and avoid veto by being added to must-sign bills
((e.g., bills to prevent shutting down the government).

Since the Republicans have never formed a consensus on the replace part
of repeal and replace, it is unlikely that they will try to enact some
of their proposed measures such as eliminating the tax preference of
employer-sponsored plans, or selling plans across state borders to avoid
effective regulatory oversight. Such efforts would create new problems
that would be unpopular - not an approach they would likely take when
they have their eye on the White House in two years.

So how does single payer activism fit into all of this? With one caveat,
there should be no change in our mission to educate our colleagues and
the public on a vastly superior alternative - a single payer national
health program. As patients experience the deficiencies of our current
dysfunctional system, they have to understand that it doesn't have to be
this way - that everyone can have their choices in essential health care
without having to negotiate financial barriers to that care.

During the next session of Congress, it is clear that we will not see
any movement on single payer legislation. Even if a wave of Republican
Enlightenment were to flood Congress and they decided that single payer
really was the preferred model, they would not allow President Obama to
receive any credit by signing the bill, but rather would wait until a
Republican President took office in 2017. Lest this seem like a fantasy,
F.A. Hayek supported "a comprehensive system of social insurance."

Our education process is two-fold: 1) describing the very positive
features of the single payer model, and 2) exposing the severe
inequities and deficiencies of our fragmented system which has only been
perpetuated by ACA. The former is obvious, but the caveat applies to the
latter.

Until we can move forward on single payer, it is important to take care
of what we do have. We should not criticize the efforts of those who are
still in the process of implementing ACA. They are doing the best they
can under current laws and regulations. If Congress tries to enact
measures that are clearly detrimental we should join our friends in
opposing such actions. If beneficial patches to ACA are proposed, we
should not oppose them merely because they perpetuate ACA, but rather
support them as transitional improvements until we can achieve single payer.

But this is where we have a problem. We need to let the public know why
these measures are inadequate - how they merely perpetuate our highly
flawed system. But we must make a clear distinction between our efforts
to make our health care system work well for everyone and the efforts of
some members of Congress who would destroy as much of ACA as they can,
and walk away leaving too many people exposed to yet more health and
financial insecurity. When we are accused of helping the enemy of reform
by opposing ACA we have to correct that misperception by letting them
know that we support ACA as a transitional program that provides some
relief until we can enact single payer, but that we cannot accept
decades of incremental changes to ACA that can never lead to a rational,
comprehensive system of health care financing.

Based on the simplistic messages that carried the election, it is
obvious that we have a formidable task ahead of us. Our messages are not
simple, but they need to be clear. Everyone can have affordable, high
quality health care, but we do not have that with ACA nor would we with
the anticipated Republican actions. We have to let people know.

Bankrate poll confirms instability of exchange enrollment

Bankrate
November 3, 2014
Obamacare users wary of new enrollment season
By Jay MacDonald

Those who experienced the rocky rollout of the Obamacare health
exchanges firsthand are feeling nervous about prices and wary of
technical glitches on the eve of the second open enrollment period,
according to the latest Bankrate Health Insurance Pulse survey. All of
the survey respondents were from households that used the exchanges
during the initial open enrollment last fall and winter.

Poll question:

Do you think you or someone in your household will again shop in a
health insurance exchange website this fall?

43% - Yes
51% - No
6% - Don't know/refused to answer


Where will the exchange-phobes go?

What about the more than half of the respondents who say they won't
return to the exchange for the second open enrollment? What's their plan B?

"That's a good question," says Kominski (Gerald Kominski, director of
the UCLA Center for Health Policy Research). "Going without insurance is
far more risky than trying to make the exchange work. My guess is they
don't qualify for a subsidy and therefore are going to shop for coverage
outside the exchange. That's a reasonable alternative because the law
regulates those so-called 'mirror' policies to where there aren't
significant differences. But I don't think there are any huge bargains
there."

Schlesinger (Mark Schlesinger, a professor at the Yale School of Public
Health) says changes in employment, income or family status also could
pull some people away from the exchange and onto either employer plans,
Medicare or Medicaid.

"Some of it may be that they're just in different circumstances," he says.

Auto-renew to avoid revisiting exchanges?

But Hough (Doug Hough, associate director of the Bloomberg School of
Public Health at Johns Hopkins University) predicts that those who
currently have exchange policies and simply don't bother to log onto
their state exchange may be surprised by the result.

"They're going to be auto-renewed," he says. "With 43 percent saying
their experience last time was somewhat or very bad, they're not looking
forward to doing it again. That in itself will encourage people to just
go with auto-renew. I predict we'll see lots and lots and lots of
auto-renewals."

http://www.bankrate.com/finance/insurance/health-insurance-poll-0914.aspx

****


Comment by Don McCanne

This Bankrate poll confirms once again what we have said many times
before. The exchanges are a highly unstable source for obtaining health
care coverage. From year to year, individuals and families cannot rely
on the adequacy and choices in their insurer-dictated networks of
providers, nor on their anticipated exposure to out-of-pocket spending
on health care.

Under a single payer system, there is no year to year process in
changing coverage. There is no necessity to use networks to limit
provider choice, plus exposure to financial hardship is essentially
eliminated by first dollar coverage.