Pay-for-Performance

At Sharp Rees-Stealy Medical Group (SRSMG), we have participated in the pay-for-performance (P4P) program for several years now, recently being recognized by Blue Cross and Aetna as the number one medical group in California in these quality measures.

P4P is an attempt to measure and reward quality. It’s not perfect. There are always questions about how each quality parameter is chosen, measured, and rewarded. A more basic question is whether quality should be measured, and, if so, whether it should be specifically rewarded. I’ve heard physicians outside our group say that better quality is something that physicians should inherently be providing, and the idea that it should be rewarded somehow takes away our professionalism. At SRSMG, we’ve decided that while it is an assumption all physicians strive to provide better quality, some physicians seem to get better outcomes than others, and we can all learn from those doing better.

It is not enough for a physician to suggest a woman should have a mammogram. If the patient leaves not appreciating the importance of getting it, or if the system to follow through with the mammogram leads to the test not happening, then the woman is at risk for later diagnosis of cancer. Likewise suggesting a woman should have a pap smear is not enough. If we can explain the purpose and motivate the patient to get the test, as well as make it convenient, then she will have a lower risk of cervical cancer.

I suspect most physicians would say they agree that having their patients undergo recommended screening tests is a good thing, and they do their best to ensure patients get such tests. Who wouldn’t agree it’s bad for diabetics to have poor glycemic control resulting in glycohemoglobin levels over 9 percent, and diabetics should have their LDL measured and well controlled? The reality is, even though we all mean well and want our patients to get these things done, sometimes it just doesn’t happen.

The more traditional way physicians have delivered this type of care was to wait for patients to schedule a physical or a specific visit to care for their diabetes or other chronic problem. If a patient didn’t schedule a physical, prevention didn’t get done. Even if patients were in the office for an acute or chronic problem, if it wasn’t a physical, then we didn’t think of prevention. Many physicians are now going to a more comprehensive style where every visit is viewed as an opportunity to deliver acute, chronic, and preventive care. This is much more challenging than a uni-dimensional visit that focuses on only one problem.

Disease management involves taking care of patients even when they have not scheduled an appointment. For example, we use our databases to generate lists of patients who appear to be in need of having a pap smear or mammogram. The support staff reviews the records to verify the patient fits the demographic criteria for the test and indeed appears to have not had it done recently. They double check with the physician to confirm the recommendation for the patient to have the test. If approved, the nurse or staff person contacts the patient and advises the patient of the recommendation and helps schedule an appointment.

A key point is the staff does the work of generating the lists of patients needing the test and checks the records, and all the physician needs to do is double check that the test is really warranted. The staff handles setting up the appointment. Physicians don’t have much extra time in their days, so it’s important to have the assistance of non-physician staff.

Another example of how we’ve learned to better manage diabetic patients is by identifying poorly controlled patients and contacting them to come in for labs and appointments. We’ve all seen diabetics who can never manage to do labs prior to their appointments or remember to bring in their blood glucose logs. We call these people in advance of the visit and remind them. In addition, for diabetics with LDLs above goal, a sheet is clipped to the progress note, essentially reminding the doctor to address the LDL at the visit. When I first saw this, I have to admit I thought it wasn’t necessary, as I “always” addressed the LDL. Many times the sheet is unnecessary, but there have been times when looking at it reminded me that I needed to address the LDL, and I’m not sure I’d have caught it otherwise. The idea is that physicians are busy and take care of many things at each visit. Anything we can do from a system perspective will help us to do better for our patients.

In summary, I think we’ve learned that while not perfect, quality measures like the ones measured with P4P are things that, when done well, are good for patients. Physicians will do better if they are prompted that patients are due for specific tests or interventions. Adequate staff support is essential to achieve the goals. Any time the patient comes in can be a chance to address acute, chronic, and preventive care. A disease or health management approach where patients needing various interventions are identified even when they are not in the office can help improve our success at enhancing the health of patients.