Stephanie S. Teleki

Pay for performance in the hospital setting: what is the state of the evidence?

More than 40 private sector hospital pay-for-performance (P4P) programs now exist, and Congress is considering initiating a Medicare hospital P4P program. Given the growing interest in hospital P4P, this systematic review of the literature examines the current state of knowledge about the effect of P4P on clinical process measures, patient outcomes and experience, safety, and resource utilization. Little formal evaluation of hospital P4P has occurred, and most of the 8 published studies have methodological flaws. The most rigorous studies focus on clinical process measures and demonstrate that hospitals participating in the Centers for Medicare and Medicaid Services-Premier Hospital Quality Incentive Demonstration, a P4P program, had a 2- to 4-percentage point greater improvement than the improvement observed in control hospitals. There is a need for more systematic evaluation of hospital P4P to understand its effect and whether the benefits of investing in P4P outweigh the associated costs. (Am J Med Qual 2009;24:19-28)

Taking Stock Of Pay-For-Performance: A Candid Assessment From The Front Lines

Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician organizations involved in the California Integrated Healthcare Associations (IHA) P4P program reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened their organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future.

Are electronic health records ready for genomic medicine

Purpose: The goal of this project was to assess genetic/genomic content in electronic health records.Methods: Semistructured interviews were conducted with key informants. Questions addressed documentation, organization, display, decision support and security of family history and genetic test information, and challenges and opportunities relating to integrating genetic/genomics content in electronic health records.Results: There were 56 participants: 10 electronic health record specialists, 18 primary care clinicians, 16 medical geneticists, and 12 genetic counselors. Few clinicians felt their electronic record met their current genetic/genomic medicine needs. Barriers to integration were mostly related to problems with family history data collection, documentation, and organization. Lack of demand for genetics content and privacy concerns were also mentioned as challenges. Data elements and functionality requirements that clinicians see include: pedigree drawing; clinical decision support for familial risk assessment and genetic testing indications; a patient portal for patient-entered data; and standards for data elements, terminology, structure, interoperability, and clinical decision support rules. Although most said that there is little impact of genetics/genomics on electronic records today, many stated genetics/genomics would be a driver of content in the next 5–10 years.Conclusions: Electronic health records have the potential to enable clinical integration of genetic/genomic medicine and improve delivery of personalized health care; however, structured and standardized data elements and functionality requirements are needed.

Using Pooled Kappa to Summarize Interrater Agreement across Many Items

We propose the pooled estimator of kappa, an efficient estimator when summarizing the interrater agreement for qualitative data with many items but few subjects. We evaluate this estimator through a simulation of proposed and alternative (average kappa) estimators and subsequently apply our method to calculate pooled and average kappas over 2,176 rated items from six semistructured interviews with sponsors of the CAHPS. The proposed pooled kappa estimator efficiently summarizes interrater agreement by domain. It is more widely applicable and makes better use of scarce subjects than simply averaging item-level kappas.

Will financial incentives stimulate quality improvement? Reactions from frontline physicians.

Pay-for-performance is being applied at the physician level to stimulate improvements in quality of care and cost efficiency; however, little is known about how physicians will respond. We interviewed physicians exposed to a financial incentive program in California to identify possible barriers to the successful application of financial incentives by exploring physicians’ opinions of and experiences with pay-for-performance programs. Reasons physicians cited for quality deficiencies included insurance coverage limitations and lack of patient compliance, time, and proper physician oversight. Physicians believe that they play a significant role and have a moderate to high degree of control over quality of care and that it is important to self-monitor. Physicians expressed the need for accurate and timely data, peer comparisons, and more patient time, staff support, and consultations with colleagues to successfully monitor and deliver quality care. Many support increased pay for delivering high-quality care but question measurement accuracy, bonus payment financing, and health plan involvement.

Patient experience of care in the safety net: current efforts and challenges.

Measuring patient experience of care fosters the delivery of patient-centered services and increases health care quality. Most pay-for-performance and public reporting programs focus on care provided to insured populations, excluding the uninsured. Using qualitative research methods, we interviewed leaders of California safety-net practices to assess how they measure patient experience of care and the measurement barriers they encounter. Most had unmet needs for assistance with data collection and quality improvement strategies for their patient population. Tailored measurement and quality improvement resources, coupled with policy mandates to give all patients a voice, would improve the quality of patient-centered care in safety-net organizations.

Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System

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A field experiment on the impact of physician-level performance data on consumers' choice of physician.

Background:In 2008, HealthPlus of Michigan introduced an online primary care provider (PCP) report that displays clinical quality data and patients’ ratings of their experiences with PCPs on a public web site. Design and Procedure:A randomized encouragement design was used to examine the impact of HealthPlus’s online physician-quality report on new plan members’ choice of a PCP. This study evaluated the impact of an added encouragement to utilize the report by randomizing half of new adult plan members in 2009–2010, who were required to select a PCP (N=1347), to receive a 1-page letter signed by the health plan’s chief medical officer emphasizing the importance of the online report and a brief phone call reminder. We examined the use of the report and the quality of PCPs selected by participants. Results:Twenty-eight percent of participants in the encouragement condition versus 22% in the control condition looked at the online report before selecting a PCP. Although participants in the encouragement condition selected PCPs with higher patient experience ratings than did control participants, this difference was not explained by their increased likelihood of accessing the online report. Conclusions:Health plan members can be encouraged successfully to access physician-level quality data using an inexpensive letter and automated phone call. However, a large proportion of missing data in HealthPlus’s online report may have limited the influence of the physician-quality report on consumer choice.