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Incentive Programs that Reward Collaborative Physician Efforts to Improve the Quality and Cost- Effective Delivery of Hospital Care


Academic year: 2021

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Incentive Programs that Reward

Collaborative Physician Efforts to

Improve the Quality and Cost- Effective

Delivery of Hospital Care


Robert D. Girard, Esq. Thomas E. Jeffry, Jr., Esq.


Physician Incentive Arrangements

We Will Discuss

A. Quality (and Efficiency) Oriented Pay for Performance ( P4P )

1. Government or third party payor sponsored programs

a) Medicare pilot programs

b) California and other group programs

2. Provider programs

a) Focus on hospital or health system sponsored programs


Physician Incentive Arrangements

We Will Discuss (cont d.)

3. Categories should not be considered mutually exclusive

a) Government and third party programs generally call for hospital/physician

collaboration and contracting commitments

b) Hospital sponsored programs will

generally involve collaboration with either existing or ad hoc physician groups


Physician Incentive Arrangements

We Will Discuss


cont d.


B. Gain-Sharing

1. Historical context and rationale for physician incentive programs

2. Advisory Process

3. DRA authorized 3-year CMS demonstration project


P4P Initiatives: Environment and Context

A. Professional and Industry Interest In Improving Quality and Questions re Efficacy of Existing

Quality Interventions

B. New Focus on Quality in Compliance Arena

C. Cost Pressures

1. Disconnect between customary practices,

legal restrictions on compensation incentives, and interest in efficiency

2. Impact of physician practices on hospital and other health system costs


P4P Initiatives: Environment and Context

(cont d.)

3. Relationship between quality and efficiency

4. HIT developments and identification of best practices

5. Consultant and other industry expertise in

developing systems to assess practice patterns and outcomes. Evidence Based Practice


6. Constraints on physician income increased interest in potential incentives


P4P Initiatives: Environment and Context

(cont d.)

D. Data Mining with Respect to All of These Factors

1. Ability to identify meaningful quality and efficiency indicators

2. Focus on critical paths , best practices, and impact of treatment decisions and resource utilization on patient outcomes


Legal Considerations Affecting P4P

Structure and Development

A. Physician Incentive Plan Law

B. Stark Law

C. Federal Medicare & Medicaid Anti-Kickback Law

D. Business & Professions Code § 650; PORA

E. Impact of Implicit Presumptions Questioning Provider Intentions

1. Risk of adverse determinations


Legal Considerations Affecting P4P

Structure and Development (cont d.)

F. Non-Profit Tax Issues

1. Private benefit 2. Private use G. Antitrust H. Corporate Practice I. Liability Issues J. Privacy/HIPAA

K. General Contract Law Issues


Practical/Programmatic Considerations

in P4P Programs

A. Data Intensive

B. Validation of Criteria, Standards, and Incentives

C. Legal Compliance Costs

D. Time and Expense Investments to Develop Programs

E. Recruitment of Appropriate Participants

F. Designing/Monitoring Effectiveness of Incentives

G. Sustainability and Flexibility (may be in conflict)


A Short History of Gain-Sharing

A. Programs Focused on Aligning Physician Incentives with Hospital Cost Savings:

1. Hospitals paid DRGs at risk for utilization

2. Physicians paid FFS no stake in hospital costs

B. Initial Favorable Tax Ruling

C. OIG Special Advisory Bulletin

1. Physician Incentive Plan Law

2. Questions under Anti-kickback Law


A Short History of Gain-Sharing


cont d.


D. Advisory Opinions and Current Regulatory Status of Gain-Sharing Programs

1. Structure approved in opinions constrains utility

2. Issues to be addressed:

a) May require significant ongoing third party input and monitoring

b) Time limited

c) Incentives limited


A Short History of Gain-Sharing


cont d.


E. CMS Gain-Sharing Study

1. Designed to improve quality and efficiency of inpatient care

2. OK if it improves hospital operational and financial performance

3. Based upon net savings for each patient


Medicare and Third Party Payer P4P Plans

Opportunities & Limitations

A. Individual Plan Initiatives

1. Contractual mandates

2. Provider tiering

B. Collaborative Initiatives:

1. Bridges to Excellence

(Boston, Cincinnati, Albany)

2. Leapfrog Group

3. Integrated Healthcare Association (California)

C. Medicare - Hospital Quality Initiative (DRA section 5001)


Developing Hospital/Health System

Sponsored Programs

A. Avoid Physician Incentive Plan Issues.

B. Built Around Quality/Efficiency Standards

1. Anti-Kickback & Stark considerations

2. Avoid arrangements that could be construed as providing incentives to refer


Developing Hospital/Health System

Sponsored Programs


cont d.


3. Be able to document that criteria, standards, and incentives are reasonable and appropriate

Use of third party expertise

Look to recognized, published standards Payments commensurate with meaningful improvements in quality/efficiency and added value to patients/payors in terms of health outcomes.

Adequate tracking, and

C. Borrow from Experience and Structure of Medicare and Third Party


Important Incentive Characteristics

(Commonwealth Fund Study;

Views of State Medicaid Directors 2007)

Uses measures other than those based on administrative or claims data (e.g., medical record reviews)

Use of measures designed to improve care, but without a requirement of cost savings

Use of nationally recognized measures Publicly reported results

Incentives are publicly disclosed in an easily understood manner by physicians and consumers

Developed collaboratively with providers

Promotes continuous quality improvement, not just target attainment

Use regularly reviewed and updated measures Feasible data collection

Scientifically sound measures

Characteristic 24% 28% 35% 41% 49% 61% 62% 70% 73% 78% Percentage Believing Characteristic is Very Important


Incentive Compensation Features

An Incentive Compensation Plan Should Be Structured to Include the Following Elements:

1. Transparency

2. Objective measures predominate

3. Clear linkages between compensation and individual and practice group goals

4. Simplicity and operational consistency

5. Income stability

6. Legal compliance

7. Shared fiscal responsibility


Incentive Performance Measure Principles

Incentive Performance Measures Should Be Reasonably Limited in Number and Should:

1. Foster care coordination among providers

2. Affect a significant number of patients

3. Be valid, scientifically sound, and tested before implementation

4. Be developed with physician input and be effectively communicated to physicians

5. Be visible, clinically relevant, and reliably define good care and optimal health outcomes


Incentive Performance Measure Principles

(cont d.)

6. Relate to factors physicians can impact

1. Scientific rationale and expected impact should be approved/accepted by

participating physicians

2. The greater the imprecision or noise in a measure, the greater the risk of unintended consequences and dampened response

by physicians

7. Be measures capable of showing improvement over time

8. Be important and understandable from the patient s perspective


Incentive Performance Measure Principles

(cont d.)

10. Encourage desired systemic changes over time

11. Be designed to maximize physician participation both initially and over time

12. Provide adequate and meaningful incentives where appropriate and feasible, incentives should reflect patient clinical complexity

13. Reward care that is of high clinical quality, patient-centered, and efficient

14. Reward both significant provider improvement and achievement of excellence


Incentive Performance Measure Principles

(cont d.)

15. Be aligned with health system or hospital goals

16. Be based on relevant and appropriate

measurement and program evaluation periods

17. Be developed with expectation of and process for review and revision over time


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