This appendix builds on the summary of P4P design principles and recommendations presented in Chapter 1 of this report. Here we present and summarize the P4P design principles established by 26 organizations representing a variety of stakeholders, including purchasers, health care providers, policy organizations, accreditation organizations, healt
What is the scope of outpatient hospital services, and which of these services could be initially targeted for performance measurement and potential reward?
Are there programs currently under way to align reimbursement with value-based purchasing (VBP) in the outpatient hospital setting?
How can hospital P4P be integrated into the Medicare purchasing environment?
What is the evidence of the impact of P4P programs on changing provider performance?
What features are necessary for the sustainability of programs?
What hospital-quality public reporting systems are currently available, and what is the evidence of their use and impact? What features (in terms of both design of the report and publicity associated with the report) of those systems are associated with greater impact?
How do private and state purchasers address the policy issues with w
What types of incentives, financial or non-financial, currently exist or are under consideration (e.g., financial, public recognition, public reporting, confidential peer comparisons, systems support)?
How effective are different types of incentives at influencing provider behavior?
Should incentives be based on thresholds, improvemen
What data collection, data management, reporting infrastructure, and data outreach were required to implement existing P4P programs (e.g., sampling methodology, storage capacity)?
How do current P4P programs address data collection issues, including sampling and minimizing burden, such as
Define the set of services provided in the outpatient hospital setting to identify what could be measured and potentially rewarded.
What measures of performance (e.g., clinical effectiveness, efficiency, patient experience, care coordination/transitions) are currently being used for both inpatient and outpatient hospital care in pra
What are the goals of existing pay-for-performance (P4P) programs and demonstrations in the hospital setting?
What should Medicare’s goals be for P4P in the hospital setting?
What is the most effective way to transition from pay-for-reporting (P4R) to P4P? What assistance should CMS offer to providers in the implementation o
Mounting cost pressures and substantial deficits in the quality of care within the U.S. health care system have led policy makers to consider options for system reform to drive improvements. Value-based purchasing is one reform option being examined and tested by payers in the public and private sectors, and it includes both financial (e.g., P4P
Among Premier hospitals that were voluntarily participating in PHQID, we found broad agreement that their decision to participate reflected a desire to “get in at the start to hopefully shape it” and a recognition that “P4P is coming, and it is a way to gain experience.” Some of the Premier hospitals that were eligible to participate but h
In our discussions with hospitals about the Medicare RHQDAPU program, which as of 2007 held 2 percent of a hospital’s APU at risk for reporting, there was widespread sentiment that they would publicly report on these measures absent the RHQDAPU effort. The historical evidence suggests the contrary, however. Prior to tying reporting of performanc
RAND drew a purposive sample of hospitals from the universe of hospitals included in the RHQDAPU program and PHQID to obtain a range of perspectives. RAND selected hospitals from the national pool of hospitals that provide services to Medicare patients, reflecting an array of characteristics:
RAND held discussions with a broad cross-section of hospitals, hospital associations, and hospital data vendors to learn about the experiences hospitals and their support vendors have had with the Medicare RHQDAPU P4R program, various private-sector P4P programs, and/or the CMS PHQID. Within the hospitals, we spoke to the Chief Executive Officer (
Not all sponsors agreed that public reporting should be a part of P4P programs. While some viewed it as an important component that compliments the financial incentive, others saw it as contentious and detrimental to creating a collaborative relationship with hospitals.
Sponsors unanimously agreed that interaction with hospitals is critical to P4P program success. They stated it was important to engage and work collaboratively with hospitals “early and often” in all aspects of the program design and operation. Sponsors noted that this builds a sense of ownership and partnership among hospitals involved, whi
The majority of P4P program sponsors advocated making the program as positive as possible. In this spirit, they suggested focusing on collaboration and rewards and avoiding financial withholds, which are viewed as punitive. This sentiment is consistent with the principle of framing noted in our review of economic theories in Chapter 2. Program s
Sponsors reported that minimizing the data collection burden was critical for hospital acceptance of P4P programs. Suggested strategies for minimizing hospital burden included (1) alignment of measures and data collection across programs and (2) selection of a reasonable number of measures to include as part of the P4P program. Sponsors were una