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The Long Run

July 1, 2007
by Mark Hagland
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As the P4P race continues, providers integrate EBM with data-gathering systems to cross the finish line.

If the pay-for-performance phenomenon was a marathon race, the winner in the first length of track would arguably be Hackensack (N.J.) University Medical Center. The 781-bed teaching hospital has been the most highly rewarded organization participating in the CMS/Premier Hospital Quality Incentive Demonstration Project (HQID) for the past two years, receiving $744,000 last year in additional reimbursement from the Centers for Medicare and Medicaid Services (CMS) for its quality improvement achievements.

Hackensack was a top performer in all five areas covered by the demonstration project for the second year in a row, with the $744,000 in award money crossing all five categories. Meanwhile, the second-place overall finisher was Charleston Area Medical Center in Charleston, W.Va., which received a total award of $701,000, the highest single award, $432,901, for providing high-quality care to 883 Medicare patients who had coronary artery bypass graft procedures. Overall, the total payout so far to hospitals in this program, the highest-profile nationwide pay-for-performance (P4P) program, is $8,690,447 for the first two years.

Peter Gross, M.D.

Interestingly, though, Hackensack senior executives say that for them, recognition from the demo project is just icing on the cake anyway. "When we got our first award, the people from CMS asked us, what difference did it make?" recalls Peter Gross, M.D., Hackensack's senior vice president and CMO. "And the answer was, it didn't. We would have done this anyway, but it was nice to get the money, and hopefully, some of the money will be plowed back into the effort."

In fact, Gross and his colleagues note that they had been focused on improving clinical outcomes quality for several years before the HQID demo project went live, and are committed to optimizing quality in their organization.

And that is one of the emerging paradoxes of pay for performance: the organizations that are doing well in P4P programs are already among the ones most highly focused on improving clinical care quality in the country. They are using evidence-based measurements backed by the clinical literature and supported by medical specialty societies and by organizations like the Washington, D.C.-based Leapfrog Group.

IT alignment a key ingredient for success

What's more, not only are the organizations leading the pack in P4P earnings strategically committed to quality improvement enterprise-wide, they have also made major investments in, and changes to, their information technology systems, in order to be effective both in measuring and reporting quality, and making improvements based on measurement. To that end, IT leadership and development are turning out to be exceptionally important to P4P success.

Barry Bershow, M.D.

For example, at seven-hospital Fairview Health Services in Minneapolis, Barry Bershow, M.D., medical director, quality and informatics, says a critical element in participating in pay-for-performance programs involves implementing computerized provider order entry (CPOE) systems that automatically facilitate clinical measurements.

"To have the ability to not only gather data, but make sure you can return the data to individual physicians frequently without bogging down your operation, is key," says Bershow, who is functioning as Fairview's acting CMIO. In other words, data-gathering must be made a part of the natural flow of automated order entry and documentation processes, he urges. When that facilitation is made possible, things can really move forward dramatically, Bershow says. Fairview (like Hackensack, a CMS/Premier demo project participant), has been running its own physician P4P program internally that has already awarded hundreds of thousands of dollars in bonus quality payments to employed Fairview physicians. Among the areas that have been focused on have been Chlamydia, obesity screening, and tobacco-use screening projects.

One obvious take-away from all this activity is the fact that implementation of advanced clinical information systems, especially electronic medical records (EMRs) becomes essential to the collection and reporting of clinical quality data, and the analysis of that data for feedback-loop improvement within hospitals, as well as in many cases the need to rework order sets within physician order entry programs.

According to Stephanie Alexander, senior vice president for Premier Healthcare Informatics, the data division of Premier Inc., the project brought the need for implementing EMRs for better measuring to the forefront. "The majority of EMRs implemented before this project did not contemplate the need to track these kinds of measures," she says. "The necessity of implementing evidence-based order sets is becoming apparent." That said, the Charlotte, N.C.-based Alexander notes that P4P programs seem to have hit their stride. "We've seen consistent, systematic improvement, across every quarter, among participants," in the CMS/Premier demonstration project, she says. Indeed, the overall quality across 30 nationally standardized clinical measures has risen by 11.8 percent in the first two years of the project, while the gap between the highest performers and others has continued to shrink, Alexander reports.