Pay-for-performance initiatives have the potential to reshape the medical landscape by incentivizing physicians to concentrate on clear goals for common diseases. However, these initiatives may focus attention on areas that are not of primary concern during a specific visit between patient and provider—which may cause physicians to miss other important quality goals. For example, if a physician spends time helping patients modify their lifestyles to lower hemoglobin A
1c levels, take beta-blockers, and have biennial retinal examinations, performance on other P4P measures (eg, Papanicolaou test) may decline. Conversely, if a patient presents with a stressful social and medical issue (eg, depression, elder abuse), the physician might spend time addressing issues that could dramatically improve a patient's life but are not part of measurement guidelines.
The P4P measures, which will be difficult to implement for many primary care physicians, may also penalize practitioners who treat patients in underserved populations that may not have the resources to follow physician recommendations. As such, there is considerable public and private value in investing and supporting the ability of these healthcare providers to participate in a P4P program and provide “best practice” physician services to their patients.
While the survey response rate was low, the current study is the largest survey of small group DOs' readiness to implement and attitudes toward P4P initiatives. However, several limitations of note exist. First, the randomized AOA mailing list did not distinguish between DOs based on specialty or practice size, limiting our ability to selectively survey physicians who met the study criteria. Second, responding physicians were concerned enough about P4P to respond to the survey, representing a response bias. Third, this survey did not explore the influences of regional differences, practice location, or alternate theoretical outcome measures. Finally, though DOs traditionally provide a greater proportion of primary care for patients per graduate, we did not survey allopathic physicians, who constitute the majority of physicians in the United States. Despite these limitations, our results indicate that a substantial number of smaller practices will have difficulty “buying into” P4P initiatives—both conceptually and technologically.
According to the current study, the majority of small group and solo-practice DOs felt that mandatory participation in existing P4P initiatives would place a burden on their practice but that personalized technical assistance would be beneficial. The Medicare Quality Improvement Organization Program does address the need for technical assistance, but these efforts are primarily focused on large practice groups.
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Two-thirds of respondents felt that their performance should be rated individually. Although this revised model may seem ideal, many individual physicians do not encounter enough patients with certain disorders to adequately apply a statistical measure to assess performance. For example, the IOM suggests a minimum of 25 patients to generate valid and reliable estimates of individual physician care per content area.
13 Alternatively, it has been proposed that individuals combine their outcomes with other physicians in their region to generate performance data on the treatment of patients with specific diseases.
14 However, whether this structure would help or hinder the individual practitioner is not clear.
14
Previous studies indicate that small group physicians have less sophisticated electronic medical record and billing resources compared with larger entities.
11,15 Although the usage rate of electronic medical records in the current study (28%) is consistent with other studies,
18 it is unclear whether these records will assist physicians in meeting P4P reporting measures.
18-20 In the current study, analysis revealed a nearly five-fold increase in the perceived ability of these physicians to comply with P4P measures.
The results of this study indicate that the development and dissemination of ambulatory quality standards alone, even when attached to monetary incentives, will not be sufficient to improve compliance with “best practices.” The healthcare community will need to ensure that small group and solo practitioners and their patients are able to meet new challenges. Many for-profit and nonprofit programs, including Bridges to Excellence Physician Office Link (
http://www.bridgestoexcellence.org/PhysicianOffice), the National Committee for Quality Assurance (
http://web.ncqa.org/), and the Agency for Healthcare Research and Quality (
http://www.ahrq.gov/qual/pay4per.htm), support and enact P4P measures for physicians but require that practice groups have existing P4P participation.
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One way to improve physician P4P readiness could be achieved by modeling the program on existing governmental programs in nonmedical settings. For example, the US Department of Agriculture Cooperative Extension System (USDA CES), a voluntary, federally authorized, interactive program, provides education, development, and technical support adjusted to meet the specific needs of local farmers via state extension offices.
22 By separating educational and support processes from oversight activity, the USDA CES has encouraged public use of the program. Such a service model might work well for the development of physician services to improve technological readiness for P4P and healthcare outcomes for patients.