Pay for Performance: Hypertension Chris Hubert, DO, is in charge of coordinating

Question

Pay for Performance: Hypertension

Chris Hubert, DO, is in charge of coordinating ambulatory hypertension care at the Cleveland clinic. Hubert is highly respected by his colleagues there, and the Cleveland clinic is proud of its excellent reputation for cardiovascular care. Hubert is an internist who has specialized in treating patients who have difficulty controlling their blood pressure. His colleagues refer such patients to him. One innovation he has introduced is to give patients graph paper so that they can record sequentially their own blood pressure measures every day at home. Patients bring their graphs to discuss the reasons why there may have been variation in what they can do to improve.

In his clinical leadership role, Hubert has been asked by a large national insurer to give advice about pay for performance (P4P) for excellent hypertension care. Three different P4P measures are being proposed. The insurer wants to know which one is the best measure of quality. It wants to know if these measures can be “gamed.” The three proposed measures are:

Pay a bonus if the patient’s and state (end of year or most recent measure) blood pressure is low (<140/90).

Pay a bonus if the patient’s blood pressure has improved after a year of care. There also must be recorded changes in prescribed medicines (titration) to show active physician involvement in care management.

Process measures only are used to measure performance. There must be documentation in the electronic medical record of screening diagnosis, follow-up care, and patient education about lifestyle changes.

Like all general internist, Hubert knows that the patient’s blood pressure can vary due to the disease, but it can vary for other reasons. The list of reasons includes measurement error, stress, relaxation, eating salty food, “white coat hypertension” (a worried patient’s blood pressure goes up just by entering the doctor’s office), which medicines are prescribed in what doses, whether the patient actually takes a medicine, and even time of day (e. g., Blood pressure can be low after a good night of sleep).

Considering these P4P measures, Hubert decided to pull up the record of one of his current patients, Mr. Norton. When Mr. Norton had first come to see Hubert, his blood pressure was high, 170/90. Mr. Norton had six office visits and there were nine medication changes. Discussions about stopping smoking were not recorded in the record, but Hubert knew they had occurred. Mr. Norton’s most recent blood pressure was 150/80. According to the proposed measures, Hubert found that he would not qualify for a bonus based upon measures 1 and 3, but he would for measure 2.

Hubert next pulled out Mr. Smith’s chart. Mr. Smith’s blood pressure remained consistently high over time, despite Hubert’s close work with Mr. Smith, including multiple calls to the patient’s home. In the case of Mr. Smith, Hubert would get a bonus according to measure 3, but not according to measures 1 or 2. With this closer review of cases, Hubert began to realize that because he was seen as an excellent physician, he tended to get referrals of really difficult cases. Under the proposed P4P system, Hubert’s colleagues-who kept the patients they could manage well-would get their bonuses, but Hubert might not. Hubert then considered how performance using these proposed measures could be gamed.

Case Questions

1. What kind of P4P measure, if any, should Hubert recommend for hypertension care? Why?

2. Do you think it would make a difference in blood pressure control if the patients were paying out of pocket?

3. Do you think Hubert’s opinion would be different if this were his whole medical groups incentive plan rather than a fee-for-service payment by an insurer?

4. Does this type of incentive plan provide equity amongst all participating physicians?

5. Might this type of scenario occur in new Value Based Purchasing contracts?

6. What discussions or interactions should Dr. Hubert have with colleagues in his practice and clinic administrators regarding the P4P plan, as well as what discussions should he have with the national insurer?

Explanation / Answer

1. The patient experience about the quality care given by the physician can be recommended as a measure for pay for performance.

2. Paying out of pocket has both effective and negative effect. Some patient's may follow the treatment regimen effectively as they spend their money . Some patient's stop taking treatment thinking to cut their unecessary expenses.

3.Absolutely yes , Hubert being a good physician struggles to get good incentive but because all the other physicians play game he cant get incentive. Fee for service payment by insurer may be effective.

4.Yes. This plan may make the physicians to give good quality care so that condition of patient and their treatment modalities improve.

5.No , because they usually identify best practices and financial quality delivered .

6. He would advice them to treat their patients in a prompt manner to reduce their Blood pressure and pay more care towards their recovery . Work for incentives but at same time provide care with good quality.

Value based reimbursement can be recommended to national insurer.

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