FOTO News

Pay-for-Performance in Health Care

Prepared for Focus On Therapeutic Outcomes, Inc.

July 23, 2011

Connolly Strategies & Initiatives
Washington, D.C.

For some years now, the number of pay-for-performance (P4P) initiatives nationwide sponsored by a variety of health plans, employer coalitions, and public insurance programs has been increasing. Several sources indicate the number in place now exceeds one hundred.1,2,3 Through these various programs, most physicians and hospitals in the United States currently face or are in discussions with local purchasers about some form of pay for performance.4 The sponsors of these incentive programs state that either rewarding or improving quality of care is a primary goal; the other goal is usually controlling costs either directly or indirectly by reducing errors and inappropriate utilization.

"Pay for performance" can include any type of performance-based provider payment arrangements including those that target performance on cost measures. Despite the growing use of P4P initiatives, there is little evidence on how best to design incentive programs in the health sector.5 Perhaps as a result of the paucity of evidence, there is tremendous variety in the approaches used in existing incentive programs.6

Existing P4P initiatives are sponsored by government purchasers (Medicare and Medicaid) as well as private employers, coalitions of employers, and health plans. Some P4P programs have been initiated by providers.7

A pay-for-performance system is a remuneration arrangement in which a portion of the payments is based on performance assessed against a defined measure. Typically, there is another component of the remuneration that is independent of the amount at risk. While most of the current discussions about pay-for-performance in the health care industry address quality-based measures, performance objectives and metrics could target any of a number of variables, including profitability, volume, or customer or patient satisfaction.7

Although often used interchangeably, pay-for-performance can also be considered one dimension of a broader set of concepts collectively known as "value-based purchasing." Proponents of value-based purchasing emphasize the focus of each decision maker, such as an insurer, employer, or patient, on assessing differences in perceived value (whether it be in efficiency, quality, cost, or some other measure) when choosing among options. The value assessment can be specific to each decision maker, and proponents of the concept prefer the positive connotation of maximizing value, typically emphasizing quality when making health care purchasing decisions. Value-based purchasing approaches emphasize the collection and analysis of data on quality, the dissemination of quality information to providers and beneficiaries, and the selective rewarding of identified high-quality achievers through contracts, partnerships, or incentives. 7

In recent years, many health care industry leaders and policy makers have joined the call to pay health care providers different amounts based on variation in the quality of their services as determined through their achievement on quality performance measures.

The elements common to all pay-for-performance programs are (1) a set of targets or objectives that define what will be evaluated, (2) measures and performance standards for establishing the target criteria, and (3) rewards, typically financial incentives, that are at risk, including the amount and the method for allocating the payments among those who meet or exceed the reward threshold.

For a pay-for-performance program to be successful, there needs to be agreement and buy-in among those being evaluated that the objectives are fair and the measures appropriate, that performance is accurately measured, and that the incentives make the effort worthwhile. Possible shortcomings and unintended consequences of a pay-for-performance program include having inappropriate measures and objectives, competing or uncoordinated efforts, insufficient or inappropriate incentives, and placing excessive focus on the reward.

Many organizations, both private and public, have recommended changes in how health care providers are reimbursed, and have suggested moving to payment methods that are at least partially based on quality differences.

Institute of Medicine. The Institute of Medicine (IOM) has issued several reports recommending differential payments based on quality. In a seminal 1999 report, To Err is Human: Building a Safer Health Care System, the IOM called for initiatives to reward quality.8 In the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM called for an increase in payments to providers of high quality care.9 This was followed in 2006 by the report Performance Measurement: Accelerating Improvement, mandated as part of the Medicare Modernization Act (P.L. 108-173), which recommends the creation of a national system for performance measurement and reporting to be financed annually through funds appropriated from the Medicare Trust Funds. One recommendation urges purchasers and insurers to redesign payments to encourage providers to make positive changes to their care processes.10 In its most recent report, Rewarding Provider Performance: Aligning Incentives in Medicare, the IOM came to two conclusions regarding pay-for-performance as a payment strategy for Medicare: (1) using payment incentives to reward quality and quality improvement "can serve as a powerful stimulus to drive institutional and provider behavior toward better quality," but (2) pay-for-performance incentives alone would be insufficient without "certain operating conditions ... such as the use of electronic health records, public reporting, beneficiary incentives, and education of boards of directors."11 These IOM reports have been influential in bringing attention to the need for quality improvement in health care and calling for variable payments based on quality.

MedPAC

For many years, Medicare Payment Advisory Commission (MedPAC) has recommended paying providers different rates based on differences in quality. In its March 2004 report, MedPAC recommended that Congress "establish a quality incentive payment policy for all Medicare Advantage plans" and "establish a quality incentive payment policy for physicians and facilities providing outpatient dialysis services."12 MedPAC added hospitals, home health agencies, and physicians to its recommendations in its March 2005 report.13 In the March 2006 report, MedPAC also recommends gathering information about resource use and providing information about practice patterns confidentially to physicians as "important steps to improving quality for beneficiaries and laying the groundwork for obtaining better value in the Medicare program."14

MedPAC's recommendations are most fully set forth in the 2005 report, which recommends that Congress give the Medicare program the ability to pay differentially based on performance. MedPAC also recommends that the Secretary of Health and Human Services (HHS) design a program that rewards both relative and absolute standards. MedPAC further recommends that the pay-for-performance system be budget-neutral, with the incentive pool to be funded by setting aside 1% or 2% of budgeted payments.13

Also of note is an open letter published in 2003 from health care industry leaders who recommend that "payment for performance should become a top national priority and that Medicare payments should lead in this effort." The signatories represented many research, academic, and insurance groups, and included several former Center for Medicare and Medicaid Services (CMS) administrators. The group noted that it was "not ... suggesting that such an initiative be dominated by government," but that a "major initiative by Medicare to pay for performance can be expected to stimulate similar efforts by private payers."15

Congress

Most of the pay-for-performance legislation that Congress has considered in recent years has centered on the Medicare program, although Medicaid and private insurers have also garnered some attention. A number of pay-for-performance demonstration projects have been authorized, and Congress issued a directive to the Secretary of Health and Human Services to develop a value-based purchasing program for hospital payment by 2009. A provision in the Tax Relief and Health Care Act of 2006, created a voluntary pay-for-performance system that rewards physicians an additional 1.5 percent of their Medicare payments for care provided, if they met reporting requirements on quality measures. 16

In 2011, with the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA), this program, now known as the Physician Quality Reporting System (PQRS) gradually evolves from voluntary status to mandatory by 2015. In other words, therapists and physicians billing Medicare must utilize and report accepted measures or run the risk of being penalized up to 2 percent of their Medicare revenue.

In preparation for such development, FOTO has been quite active in the Medicare arena since 2002. The company has also submitted and successfully navigated the difficult waters of third-party evaluation to earn approval of seven of its measures. The independent third party recognized by Congress and CMS is the National Quality Forum (NQF) which first endorsed FOTO's functional status measures in 2009. The following year, CMS accepted the measures for use in the PQRS program. At the same time, FOTO sought and was granted recognition by CMS as PQRS Registry which allows FOTO to collect and submit measurement data to CMS on behalf of its customers.

The Balanced Budget Act of 1997 created annual per beneficiary monetary caps on physical and occupational therapy. These caps were intended to be temporary until "an alternative payment method" could be established. CMS has studied therapy utilization and issued some reports to Congress but has yet to identify the alternative. Meanwhile, Congress has waived the application of the cap several times. In 2006, Congress granted CMS the authority to implement an exceptions process to the therapy caps. In developing this process, CMS used Transmittal 63 to identify four patient assessment instruments that, if used, would provide clinicians whose care for a patient exceeded the monetary cap, justification for such utilization. FOTO was, and remains, one of those recognized instruments. 17

Also in 2006, with the assistance of an earmarked appropriation (a grant) garnered by FOTO's Washington lobbyist, the company completed for CMS a pay-for-performance feasibility study for the rehabilitation therapies.18

The purpose of the project was to implement a pay-for-performance simulation, which would align financial incentives with the achievement of better clinical outcomes. The project was designed to demonstrate the feasibility of implementing a pay-for-performance process in outpatient physical and occupational therapy, provide information to Medicare concerning payment policy for outpatient physical and occupational therapy, and discuss implications for the development of an alternative payment method as required by Balanced Budget Amendment of 1997.

The results support that, by implementing a risk-adjusted pay-for-performance method in outpatient physical and occupational therapy, the system could be moved closer to the Institute of Medicine's vision of the future health care delivery system that is effective, patient-centered, timely, efficient and equitable. Given that the pay-for-performance process is not provider or treatment specific, the method should encourage clinicians to practice evidence-based practice and develop best practices designed to achieve better patient functional status outcomes efficiently. Using an outcomes measure of change in functional status associated with a measure of efficiency, i.e., number of treatment visits, the data can be used to develop guidelines for payers designed to improve the objective management of providers. The pay-for-performance process demonstrated presents an alternative payment method worthy of consideration, possibly as a replacement of the therapy caps.18

The report was well-received by CMS and highlighted the strengths and weaknesses as well as the challenges and the ultimate benefits of creating a system in which care would be based on need and payment based on results. The experience and end product also contributed to the inclusion of FOTO as a recognized patient assessment instrument in the CMS Transmittal 63.

The PPACA of 2010 also codified a movement in health service reimbursement away from fee-for-service and toward effectiveness, efficiency and coordination of care. This paradigm is also a form of value-based purchasing in that it creates a method by which providers can share in savings that might be generated by less costly but more effective care.

Section 3022 of the PPACA which created the Medicare Shared Savings program, also known as Accountable Care Organizations(ACOs), specifically requires such ACOs to monitor the effectiveness of and patient satisfaction with services rendered. The Shared Savings Program, which is not a pilot, is to be established by January 1, 2012.

Physical and occupational therapists are included in this paradigm as "ACO Participants." And since the emphasis in such a delivery model will be on effectiveness and efficiency, professionals who employ tools like FOTO's measurement instruments will be in a position to demonstrate functional outcomes of intervention as well as the cost-effectiveness of their care.19

Past Related Legislative Activity

In recent years, Congress has considered legislation that would implement pay-for- performance in health care. Most of the efforts have centered on the Medicare program, although Medicaid and private insurers have also garnered some attention.

A number of pay-for-performance demonstration projects have been authorized, and Congress issued a directive to the Secretary of Health and Human Services to develop a value-based purchasing program for hospital payment by 2009. H.R. 6111, the Tax Relief and Health Care Act of 2006, creates a voluntary pay-for-performance system for physicians who serve Medicare patients that will pay bonuses based on the satisfactory reporting of quality measures.

S. 1932/Deficit Reduction Act

In the fall of 2005, during the budget reconciliation deliberations that led to the Deficit Reduction Act of 2005 (P.L. 109-171, DRA), the Senate passed S. 1932, a bill that contained language to establish a pay-for-performance program under the Medicare program.20 The proposals in S. 1932 would have established value-based purchasing systems for each of the different Medicare providers. There would be separate value-based purchasing programs for hospitals, physicians and other practitioners, Medicare managed health care plans and prescription drug plans, ESRD providers and facilities, home health agencies, and skilled nursing facilities. Although the specifics of each program differed in the details, they all shared some general principles.

  • The value-based purchasing programs would begin collecting data on quality measures in the initial year of establishment, with incentive payments disbursed in subsequent years. Data from the initial year would be used to inform providers what their payments would have been for the year had the value-based purchasing program already been in place.
  • Following a recommendation of the Medicare payment Advisory Commission (MedPAC), each value-based purchasing program would create an incentive pool funded by withholding up to 2 percent of total payments to that category of provider. The percentage of funds that goes towards the incentive pool would not decrease over time, and all funds collected for the year incentive pool must be paid to qualifying providers as incentive payments under the program for that year.
  • Participation in the value-based purchasing program would be voluntary, but providers would be required to report quality data in order to be eligible for incentive payments.
  • Incentive payments would be paid to providers who meet certain thresholds for quality measurement. These thresholds would be based on either relative or absolute standards.
  • The quality measures would be specific to each category of providers and would be revised over time, but the measures would be required to be evidence-based, easy to collect and report, address process,structure, outcomes, beneficiary experience, efficiency, over- and underuse of health care, and to address disparities in health care provided and health outcomes between majority and minority groups.
  • In the initial year, the measures would include at least one measure of health information technology infrastructure.
  • Because all the funds collected under the value-based purchasing programs would be paid out as incentive payments, the total payments over time would not change as a result of these provisions, but the timing of the incentive payments would be delayed a year compared to payments made in the absence of the value-based purchasing programs.

Eventually, only two pay-for-performance provisions from those deliberated as part of the DRA passed and became law: section 5001(b) requires that the Secretary of Health and Human Services (HHS) develop a plan to implement a value based purchasing program for Medicare hospital payments beginning with FY2009, and section 5201(d) requires MedPAC to develop recommendations for a value based payment system for Medicare home health services.21

The requirement for the development of a hospital pay-for-performance system for Medicare payments does not include detailed specifics about such a program. The general guidelines contained in the statute require the value-based purchasing program to include the following: on-going development, selection, and modification of measures of quality and efficiency in hospital inpatient settings; the reporting, collection, and validation of quality data; the establishment of thresholds and standards that would substantiate value based payments and the source of such funds; and the disclosure of information on hospital performance.22

DRA also included a provision that requires MedPAC to develop recommendations for a detailed structure of value based payment adjustments for home health services under the Medicare program by June 1, 2007. Specifically, the report is to include recommendations concerning the determination of thresholds for payments, the size of value based payments, the sources of funds for these payments, and the relationship of payments to the improvement and attainment of quality.

H.R. 3617

In July 2005, Ways and Means Health Subcommittee Chair Johnson and several co-sponsors introduced the Medicare Value-Based Purchasing for Physicians' Services Act of 2005. This bill would establish a value-based purchasing program under Medicare based on measures of quality ("Q-measures") and efficiency ("E-measures").

Among other things, these measures were to be, "evidence-based, if pertaining to clinical care, ... consistent, valid, practicable, and not overly burdensome to collect, ... and relevant to physicians and other practitioners [and Medicare beneficiaries]." Each physician specialty organization would have been requested to submit measures to a "consensus-building organization," such as the National Quality Forum, that would then submit recommendations to the HHS Secretary. The measures would be used to rate physicians to determine whether the physicians' billing unit would be eligible for the performance incentive (an increased annual update).

H.R. 6111, the Tax Relief and Health Care Act of 2006

In December 2006, Congress passed legislation implementing a voluntary quality reporting system that ties a portion of the payments for Medicare professional services to the reporting of claims data.54 Physicians and other eligible professionals who provide health care services to Medicare beneficiaries between July 1 and December 31, 2007, and who satisfactorily report the quality information, would be eligible for a bonus payment based on their Medicare reimbursement for the same period. The pay-for-performance measures to be used as the basis for this bonus are borrowed from an existing CMS program. For covered professional services furnished beginning July 1, 2007, and ending December 31, 2007, the quality reporting measures are those identified as physician quality measures under the CMS Physician Voluntary Reporting Program (PVRP). The set of quality measures may be modified until April 1, 2007; however, no measures may be added or removed after that date, although modifications or refinements to previously published quality measures are allowed (without notice or opportunity for public comment) up until July 1, 2007. To qualify for the bonus, providers must meet reporting guidelines. Eligible professionals who (1) furnish services for which there are established quality measures as described above and (2) satisfactorily submit quality measures would be paid a single additional bonus payment amount equal to 1.5 percent of the allowed charges for covered professional services furnished during the reporting period. The bonus incentive payments would be paid from the Supplemental Medical Insurance Trust Fund (Part B).

Satisfactory reporting of data determines whether the provider is eligible for the bonus payment. If there are no more than three quality measures that are applicable to the professional services provided, the provider must report each measure for at least 80 percent of the cases to meet the criteria. If there are four or more quality measures that are applicable, the provider must report at least three of the quality measures for at least 80 percent of the cases.

CMS would have the authority to determine whether providers qualify for and receive the bonus. This would include the ability to validate (by sampling or other means) to determine if the reported measures are applicable to the professional services provided. If CMS determines that an eligible professional has not reported applicable measures, the provider would not receive the bonus. The provision also places a limit on bonus payments.

The pay-for-reporting program established by H.R. 6111 might be transitory. For 2008, the quality measures would change to a set of measures adopted or endorsed by a consensus organization (such as the National Quality Forum or AQA, originally known as the Ambulatory Care Quality Alliance) that includes measures that have been submitted by a physician specialty developed through a consensus-based process.

The CMS administrator would publish a proposed set of quality measures for 2008 in the Federal Register no later than August 15, 2007, with a public comment period. The final set of measures appropriate for eligible professionals to use to submit quality data in 2008 would be published no later than November 15, 2007. H.R. 6111 does not specify what bonus, if any, would be obtainable in 2008.

Proposals that incorporate pay-for-performance components for reforming public health care programs such as Medicare are likely to continue to come before Congress. While the potential for improving the quality and efficiency of health care is encouraging, the claims of improved quality with simultaneous cost savings will undoubtedly be carefully weighed against the evidence of proven results that can be generalized to larger populations and other settings and situations in the health care industry.

CMS Pay-for-Performance Initiatives

Pay-for-performance

Program Summary Description

Hospitals

 

Hospital Quality Initiative [MMA Section 501(b) and Deficit Reduction Act (DRA) Section

5001(a)]

All hospitals are required to report a set of quality measures in order to receive the full Medicare DRG update. Under MMA, hospitals that didn't report would have received the market basket update less 0.4 percent in 2005 and 2006. DRA increased the

amount at risk to 2 percent in 2007 and subsequent years and expanded the measure set.

Premier Hospital Quality Incentive Demonstration

Financial incentives are offered to 260 hospitals for high quality, as demonstrated on 34 quality measures relating to five clinical conditions. Hospitals scoring in the top 10 percent will receive a 2 percent

bonus payment. Those scoring in the next highest 10 percent will receive a 1 percent bonus. In the third year of the demonstration, those hospitals that do not meet a predetermined threshold score on quality measures will be subject to reductions in payment.

Physicians or Integrated Health Systems

 

Physician Group Practice (BIPA 2000)

Ten large (200+ physicians) groups earn performance-based Medicare fee-for-service payments on quality results. The demonstration seeks to encourage coordination of Part A and

Part B services, promote efficiency through investment in administrative structure and process, and reward physicians for improving health outcomes.

Case Management Performance Demo (MMA Section 649)

A three-year pay-for-performance demonstration with physicians to promote the adoption and use of health information technology to improve the quality of patient care for chronically ill Medicare patients. Focused on small and medium-sized physician practices, this demo will be

implemented in four states: Arkansas, California, Massachusetts, and Utah, with the support of the Quality Improvement Organizations in those states.

Health Care Quality Demo (MMA Section 646)

A five-year demonstration program under which eligible physician groups, integrated health systems, or regional coalitions of the same, aim to enhance quality by improving patient safety, reducing variations in utilization by appropriate

use of evidence-based care and best practice guidelines, encouraging shared decision making, and using culturally and ethnically appropriate care.

Disease Management/Chronic Care Improvement

 

Chronic Care Improvement Program

(MMA Section 721)

Participating organizations are paid a monthly per beneficiary fee for managing a population of chronically ill beneficiaries with advanced congestive heart failure and/or complex diabetes

to test a population based model of disease management. Payment of fees is contingent upon performance on quality measures and satisfaction of both beneficiaries and providers. After two years, pending successful interim results, this pilot

may be expanded more broadly, possibly nationally.

ESRD Disease Management Demonstration (MMA

Section 623)

This 3-year demonstration will test a fully case-mix adjusted payment system for an expanded bundle of end stage renal disease (ESRD) services. A portion of the payment will be linked to ESRD-related quality measures.

Disease Management Demonstration for

Severely Chronically Ill Medicare

Beneficiaries (BIPA 2000)

This demonstration, which began enrollment in February 2004, is designed to test whether applying disease management and prescription drug coverage in a fee-for-service environment for

beneficiaries with illnesses such as congestive heart failure, diabetes, or coronary artery disease can improve health outcomes and reduce costs.

Disease Management Demonstration for

Chronically Ill Dual Eligible Beneficiaries

Disease management services are being provided to dually (Medicare & Medicaid) eligible beneficiaries in Florida who suffer from advanced-stage congestive heart failure, diabetes, or

coronary heart disease. The demonstration combines the resources of what had previously been the state's Medicaid pharmacy benefit with a disease management activity funded by

Medicare to coordinate the services of both programs, with the goal of improving quality while lowering total program costs. The demonstration organization is being paid a fixed monthly

amount per beneficiary and is at risk for 100 percent of its fees if performance targets are not met.

Care Management For High Cost Beneficiaries

This demonstration will test models of care management in a population of high-cost and high-risk Medicare fee-for-service beneficiaries. Participating providers are required to meet

relevant clinical quality standards as well as guarantee savings to the Medicare program.

Source: CMS [http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343 ].16

 

Private Sector Examples

  • UCare's P4P program paid $2,445,250 to clinics and care systems across Minnesota for their performance in key quality-of-health measurements achieved in 2008. The payments recognized and rewarded providers for superior or improved performance in measurable key areas for care delivered to members of UCare's Minnesota Health Care Programs (MHCP). UCare's payments for improvements in key measurements increased 58 percent over 2007 results. This increase came primarily from clinics and care systems that have historically participated in UCare's P4P program. UCare paid $1,499,800 to 546 eligible care systems and independent clinics serving MHCP members, an increase of 46 percent from 2007. Total Medicare payments were $945,450, an 825 increase in payments from 2007.
  • A UCLA study revealed that patient-care performance ratings for 25 medical groups across California improved significantly following the launch of a statewide patient-care performance in 2004. But Incentives focusing on doctor productivity were a different matter.
  • Hector P. Rodriguez, assistant professor in UCLA's School of Public Health and his colleagues found evidence that certain kinds of financial incentives for the purpose of improving patient care, in combination with public reporting of medical group performance ratings, have a positive effect on patient care experiences. They also found that some types of incentives may have a negative overall impact on how patients experienced their care.
    Rodriguez looked at how medical group performance ratings changed over time and found that ratings in specific measures, representing three broad categories " physician communication, care coordination and office-staff interactions " improved substantially during the period after the start of the Integrated Healthcare Association's (IHA) patient-care performance program.

    Incentives for addressing the quality of patient-clinician interaction and the overall experience of patient care tended to result in improved performance in those areas, especially when the additional funds were used broadly by medical groups to positively reinforce a patient-centered work culture.

    The greatest improvements were seen within those groups that placed less emphasis on physician productivity and greater emphasis on clinical quality and patient experience. Within groups where financial incentives were paid directly to physicians, Rodriguez found that placing too much emphasis on physician productivity actually had a negative impact on the experiences patients had when visiting their primary care physician.
  • Spectrum Health of West Michigan joined the national payment reform pilot, funded by the Robert Wood Johnson Foundation (RWJF) with over $6.4 million in grants for the life of the project. The pilot has been adopted by four healthcare regions to test provider payment reform for outcomes margins evidence transparency hassle-reduction excellence understandability and sustainability (PROMETHEUS) payment model.

    Realizing the healthcare need for a new payment model that rewards quality care and not quantity and recognizing the need to slowly implement a new payment model to avoid, as PROMETHEUS' design team leader and national coordinator Franois de Brantes described as, trying to turn around a Mack truck speeding down the payment superhighway at about 80 miles per hour and gaining speed as it goes, the evidence-based case rate model was created.

    "The physicians, medical groups and hospitals participating in these sites have different characteristics and taken together they should provide some good insights to the potential for an episode of care payment model such as PROMETHEUS to improve quality and lower total cost of care," de Brantes said.

    Minneapolis, Min., Rockford, Ill. and Chester, Pa. are the other areas PROMETHEUS will be used to pay for healthcare.

References

  1. Baker G, Carter B. The evolution of pay for performance models for rewarding providers. Introduction to: Case Studies in Health Plan Pay-for-Performance. Washington, DC: Atlantic Information Services; 2004.
  2. Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association. 2003;289(4):434-41.
  3. The Leapfrog Group. Leapfrog Compendium. www.leapfroggroup.org/ircompendium.htm Accessed August 25, 2005.
  4. Steiger, B. Poll finds physicians very wary of pay-for-performance programs. The Physician Executive, November/December 2005: 6-11.
  5. Dudley RA, Frolich A, Robinowitz DL, et al. Strategies To Support Quality-based Purchasing: A Review of the Evidence. Technical Review 10. (Prepared by the Stanford-University of California San Francisco Evidence-based Practice Center under Contract No. 290-02-0017). AHRQ Publication No. 04-0057. Rockville, MD: Agency for Healthcare Research and Quality. July 2004.
  6. Baker G. Pay for Performance Incentive Programs in Healthcare: Market Dynamics and Business Process. San Francisco, CA: Med-Vantage; 2004
  7. Pay for Performance: A Decision Guide for Purchasers, Agency for Healthcare Research and Quality, Publication No. 06-0047, April 2006
  8. Institute of Medicine, To Err is Human: Building a Safer Health Care System, National Academy Press, Washington, DC, 1999.
  9. Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press, Washington, DC, 2001.
  10. Institute of Medicine Performance Measurement: Accelerating Improvement, National Academy Press,Washington, DC, 2006.
  11. Institute of Medicine, Rewarding Provider Performance: Aligning Incentives in Medicare.National Academy Press, Washington, DC, 2006.
  12. MedPAC, Report to the Congress: Medicare Payment Policy, March 2004.
  13. MedPAC, Report to the Congress: Medicare Payment Policy, March 2005.
  14. MedPAC, Report to the Congress: Medicare Payment Policy, March 2006.
  15. Berwick, DM et. al. "Paying for Performance: Medicare Should Lead," Health Affairs Volume 22, Number 6, November/December 2003. pp. 8-10.
  16. Pay-for-Performance in Health Care,Congressional Research Service, December 2006.
  17. Transmittal 63, Pub 100-02 Medicare Benefit Policy, Centers for Medicare & Medicaid Services, December 29, 2006.
  18. Pay-for-Performance for Physical Therapy and Occupational Therapy: Medicare Part B Services, Report to CMS, Grant #18-P-93066/9-01, Focus On Therapeutic Outcomes, Inc., 2006
  19. Patient Protection and Affordable Care Act of 2010, Section 3022, Medicare Shared Savings Program
  20. S. 1932 contained many elements of S. 1356, the Medicare Value Purchasing Act of 2005,a bill introduced by Sen. Grassley at the end of June 2005.
  21. Another provision establishes quality adjustments in Medicare inpatient hospital paymentsfor certain hospital acquired infections, but not in a pay-for-performance framework.
  22. P.L. 109-171, Section 5001(b).
  23. UCare Says Data Show Its P4P Program Works, Managed Care Information Center, June 29, 2010.
  24. P4P Programs Help Improve Care - Most Of The Time, Journal of General Internal Medicine. Managed Care Information Center, March 29,2010.
  25. Spectrum Health Joins PROMETHEUS Pay Model Pilot, Managed Care Information Center, May 18, 2010.