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    High Performance

Paying Providers

Based on a review of public documents from Value Based Programs (VBP) government sources are presently employing a relatively narrow set of evaluation measures as the basis for differential provider service payments. The measures vary somewhat by the health care settings in which they are being deployed as well as by the type of VBP model. Historically Performance for Pay (P4P) programs have focused on quality performance, while the newer VBP models, (Accountable Care Organizations (ACO’s) and bundled payments) provide financial incentives providers for both cost and quality.

Pay for Pay Programs (P4P) – typically include measures of clinical process and intermediate outcomes (e.g., Healthcare Effectiveness Data and Information Set (HEDIS) or Joint Commission or CARF patient safety standards.

The Accountable Care Organization (ACO’s) program models being tested by the Centers for Medicaid and Medicare Services (CMS) use 33 measures, which include Healthcare Effectiveness and Information Set (HEDIS), is a tool used by more than 90 %of America’s health plans to measure performance on important dimensions of care and service. Examples include clinical processes and intermediate outcomes; all-cause hospital re-admissions; ambulatory sensitive care hospital admissions; patient safety; and electronic health record (EHR) functionality. The measures included in bundled payment programs tend to vary by the condition or procedure included in the episode as well as the setting(s) in which care is delivered. Cost measures are most commonly used.

Because many plans utilize HEDIS data it makes it possible to compare the performance of health plans. This information has been designed to provide both purchasers and consumers of health services the information they need to reliably compare the performance of health plans. Users benefit from the largest data base of comparative performance information to conduct competitor analysis, examine quality improvements  and benchmark plan performance.

In the hospital setting, where most bundled payment programs are now occurring, evaluation measures include clinical process, patient safety, re-admissions, mortality, length of stay, and total cost of care. Some programs have been able to avoid tying physician compensation to outcome measures, so that physicians will not hesitate to treat patients who are more complicated. Little public information is currently available regarding the precise measures that are being used in ambulatory care bundled payment programs.

Government sponsored Value Based Program models in operation are intended at some point, to require all providers move to patient-reported outcome measures. Determining which patient outcome standards will be applied to providers is still under consideration.