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FOTO Rehab Outcomes Blog

Pay for Performance Structure

Many of the things I see on the internet have me pause and think. The other day I ran across a particular page that was dedicated to an incentive program. The payer decided to implement a pay for performance program. A particular quote immediately came to mind.

"Each waking moment is a rung on the endless ladder. Each step we take is built on what has gone before." ~Kung Fu Wise advice to us grasshoppers.

Since I live in Michigan, I have been fully aware that Priority Health was planning on implementing an incentive program for physical therapists and the services they provide. I applaud the intent of the payer. This program rolls out tomorrow (at the same time we all need to be ready for ICD-10 coding).

Although I applaud their intent, I do not believe this program is patient-centered enough. Okay... it does include if a patient believes their goals were met or partially met. I suppose that is a nice component.

I have issues in three areas. First, patient factors are not risk adjusted. I know this from communication with Jessica Quick. Her response about risk adjusted factors was, "There aren’t currently any risk adjusted factors.  The incentive is based on the five categories listed on our website."  Second, the program is based on a score comprised of 5 categories.The categories are equally weighted. Should each category be equally weighted? Third, I don't like the way 3 of the 5 categories are defined.

The categories include: 60% of all Priority Health patients need a completed episode, 50% of patients need to report satisfaction with the care provided, I have no clue what is acceptable improvement in pain, I have no idea what percentage of patients need to convey their goals were met, and minimal clinically important difference (MCID) was met for whichever of 5 tools was used to capture function.

As the Kung Fu quote indicates, we grow from the foundation we build... the problem, are payers willing to change contracts as they learn?

I can assure you, there is no way I would enter into this contract. How can I enter into a contract when a contract is using aggregated data to determine the incentive when patient factors are not risk adjusted? I'm not going to enter an incentive program where I have a potentially high risk of the data not indicating quality care was provided due to lack of patients being equalized. If Priority Health provides me data that their patients are a homogenous group, maybe I'd reconsider my thought. Without data from the payer, I'd much rather protect myself by ensuring a strong risk adjustment process is included in the program.

From what is written on the website, the incentive program is too vague. The desired percentage of improvement in pain level is not defined. The percentage of patients who need to report that their goals were met is not defined. Why in the world would I choose to enter an incentive program when 2 categories are that vague? I have no clue what I need to meet in those categories to score the most. My final issue with the program revolves around MCID.

Although MCID sounds like a nice, scientific way to determine quality care was met, it is problematic. First, research has grown in the last 5-10 years in looking at these tools and MCID. Literature indicates that various patient populations may have different MCID for the same tool. Second, is MCID a reasonable category? I say not necessarily. I know from using FOTO that some patients are not predicted to reach a MCID amount of change due to their individual factors. I know that for some patients the prediction indicates they may worsen. I know others are predicted to far surpass MCID. Third, shouldn't the patient's current functional level be considered? Let's say a patient begins services after a surgical procedure. The patient will definitely attain a MCID amount of change quickly. Is that enough of a basis to determine quality occurred? I say no. For that scenario, the patient may have a potential of attaining far more improvement than just MCID. It can be very short sighted to focus only on reaching a MCID amount of change, especially from a patient's perspective.

So, Dear Grasshoppers, just because a payer has an incentive program doesn't mean you should automatically decide to participate. Read the program closely. Determine if you can meet the defined quality level. Ask for data about the subscribers. Don't assume all the risk. 

Does anyone have any other thoughts or comments?

Until next time,