Epstein2004NEJM - The n ew england journal of m edicine s...

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The new england journal of medicine n engl j med 350;4 www.nejm.org january 22, 2004 406 sounding board Paying Physicians for High-Quality Care Arnold M. Epstein, M.D., Thomas H. Lee, M.D., and Mary Beth Hamel, M.D. The recent call from the Institute of Medicine for government payers to increase payments to health care providers who deliver high-quality care is one of several signs that practicing doctors can expect some fundamental changes in the way they are com- pensated. 1,2 Health care insurers and purchasers in the private sector have begun moving along a simi- larly ambitious path. Many physicians are already familiar with quality incentives from their experience with managed care; such incentives began as small payments for higher ratings of patient satisfaction or for the use of pre- ventive services such as mammography. 3 These in- centives have become so prevalent that physicians are more likely to receive financial incentives for improving the quality of care or patient satisfaction than for controlling the use of services. 4,5 Anecdotal information also suggests that the amount of money being used as an incentive is growing substantially. Perhaps the real harbinger is the National Health System in the United Kingdom, which has recently adopted a payment-for-performance initiative of unprecedented size and scope. Nearly a third of a general practitioner’s income will depend on the practitioner’s performance as defined by 130 qual- ity indicators. 6-8 In this article, we discuss pay- ment-for-performance initiatives — their origins and goals, the challenges they present, and the strat- egies that payers might use to overcome the chal- lenges most effectively. Several factors account for the increased interest in financial rewards to physicians for providing care of high quality. Quality measurements and moni- toring have become more sophisticated. Indicators are now available to assess the treatment of a broad array of chronic diseases (e.g., asthma and conges- tive heart failure) and the appropriate provision of preventive care. The most prominent quality report card, the Health Plan Employer Data and Informa- tion Set (HEDIS), published annually by the Na- tional Committee for Quality Assurance, reflects the quality of care patients are receiving in health plans that cover 75 percent of Americans enrolled in man- aged care. 9 These national efforts to monitor the quality of care, 10 as well as individual studies, 11-13 have illu- minated serious shortfalls in the quality of clinical care in many areas. At the same time, longitudinal data on HEDIS scores 10 and other measures of qual- ity nationally 14 indicate that these measures can spur meaningful improvements through the intro- duction of systems that enhance the reliability of delivery of key interventions. Nonetheless, prior models of health care delivery and physicians’ pay- ment failed to prevent gaps in the quality of care, as described in two reports from the Institute of Med-
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This note was uploaded on 04/14/2011 for the course ECON 329 taught by Professor Classen during the Spring '11 term at Loyola Chicago.

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Epstein2004NEJM - The n ew england journal of m edicine s...

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