One of the keys to launching a pay-for-performance program is a tough one for physicians: don’t try to get it perfect. This unusual advice comes from Dr. David Blair, president and CEO of Grand Rapids, Mich.-based Advantage Health Physicians. And Blair ought to know, his organization has been paying its physicians quality-based bonuses for more than 12 years.

“You need to understand this is where the nation is going—the public wants it, employers want it. You’d better join this process and then figure out how to move it through your organization the best you can,” said Blair. “If you don’t start now, it will be thrust on you by outside groups.”

Blair is candid about the difficulties of P4P programs. “There are so many mistakes in this process,” he said. “You’re got members that dropped their insurance a month before so they don’t qualify any more. You wind up with men on a registry to get a mammogram. All these plans are screwing that kind of thing up.”

But he’s adamant that such programs are a critical component of revamping the healthcare system. “People want to do a good job—staff like this stuff, doctors like it,” he said. “When it doesn’t get too punitive, people enjoy seeing things like the hemoglobin scores improving. We had 93% of our female patients getting pap smears last year. You feel good about yourself and about your team when you’re successful.”

Running in and out of rooms
Blair has been with AHP for 12 years, the last two as CEO. His background prior to that was with an HMO, which influenced the organization’s quality initiative. “I knew what NCQA was and what HEDIS expectations were. I knew that this idea was growing and that plans were interested in performing against those targets,” he explained.

The physicians in the group agreed. Blair: “They said, ‘You want to pay us for productivity—you want us to run in and out of rooms quickly—but we should be paid in part on quality.’”

Thus, one of the group’s founding ideas was quality. “We knew we need to be financially reponsible, and that’s also in our mission statement, but quality matters to us,” said Blair. Twelve years ago, the program was fairly rudimentary. “We created quality targets and bonused our doctors up to $5,000 per year to hit targets related to diabetes and cancer screening.”

Four years ago, the program was expanded significantly as technology improved and discussions of P4P became more prevalent. “With our inhouse IT department, we have the ability to follow patient data, and we are out to provide quality on a population basis,” Blair said. “This is a common managed-care perspective, and an employer perspective, but it’s not a natural physician perspective.”

Generally, physicians tend to simply see the person who is on their schedule that moment, Blair said. “A primary-care physician can impact the 10 to 15 patients on their schedule in an afternoon. They can’t think about the thousands of patients not on their schedule.”

Blair’s group thinks differently. “We wanted to be more accountable, to do the best we can for that whole population. The patients may or may not know that it’s appropriate for us to be thinking about them. But the insurance companies know it, HEDIS knows it—and the employers are driving it.”

Mistakes have been made
Today, the physician group has 100 primary care physicians and is part of the Saint Mary’s Health Care system, which is in turn a member of Trinity Health. Instead of the $250,000 internal bonus budget it started with, physicans are rewarded for quality by payer companies, including Priority Health and Blue Care Network.

Switching from internal to external payments was tricky. “We set up registries so we could track patient populations. When we depended on them to do this, they made mistakes,” said Blair.

“It’s so complicated that it’s difficult to eliminate errors completely,” he explained. “Say someone’s insurance wants them to have a mammogram, and it’s the husband’s insurance that’s checking for a mammogram for the woman in the household before paying the bonus, but her PPO insurance paid for the mammogram. If the
radiology department doesn’t bill the second insurance, you get no credit for her getting a mammogram, even though she got it. That type of error is lessening, but it’s not gone.”

AHP has been very proactive in this area, using technology to support its P4P efforts. Blair noted that three years ago, Trinity Health put in a Cerner system that gave providers a number of results reports. “Suddenly, we had hemoglobin A1c values, radiology reports, pap smear reports, and so on. It allowed our IT dept to build a data warehouse.”

At that time, the warehouse only contained data on HMO patients. This was a good start, but hardly satisfactory to Blair and his group. “We had maybe 1,200 of our several thousand diabetics in a registry,” he said. “We wanted to get past that so we were providing the best care for a population, not just an insurance population.”

AHP began creating global registries for physicans based on its billing system, beginning with a five-doctor pilot. In he midst of the pilot, word came from Blue Care Network that they wanted to support this type of effort for Michigan physicians. About 60 physician groups wrote applications to participate in the program, and AHP was chosen as one of the initial 10 (there are now 15 physician networks in the program).

“By winter of 2005, they told us they wanted us writing global registries, starting with one topic and eventually encompassing diabetes, congestive heart failure, coronary artery disease, and asthma.”

Blair is pleased with the program, noting that Blue Care has been more concerned with process than with physicians hitting certain percentages, realizing that different physicians care for different percentages of Medicaid and uninsured patients. “They earmarked about $10 million to be paid out for instrastructure and to reward processes that would lead to these registries,” he said.

Re-engaging patients
Some of the groups are still in the process of building the registries; AHP is ahead of the curve. “We have between 5,500 and 6,000 diabetics in our registry. In my registry, I have 130 diabetics with their name, the date of their latest A1c, LDL, eye exam, and so on,” he said, noting that when AHP patients go for an eye exam, they bring a form to be signed and faxed back on completion of the exam.

Blair believes the re-engagement with the patient that is the result of this type of program is essential to changing the healthcare system. “When we’re persistant, many patients start to get it and cooperate much more,” he said. The group is applying its success with diabetes (50% of patients had a hemoglobin level under seven on their last test) to other areas, including mamograms, pap smears, pediatric immunizations, and athsma.

For example, the RN or LPN in charge of quality in a particular office might call an asthma patient to let them know their medication needs to be reviewed if they’re using too much rescue medicine and need a controller medicine. Next on the list is getting all appropriate patients in for a colonoscopy, Blair said.

AHP has not yet released its quality numbers to the public, although they are reviewed internally and with payers on a regular basis. But Blair believes once the overall processes are improved, this type of information should be available publically for all healthcare providers.

“It’s awkward because we know all the mistakes that can get made and that not everyone’s populations are the same,” he said. “But if you think about it from a broader perspective, when you buy a car, you want to know what Consumer Reports says about it. Why should we in healthcare think that the public is not entitled to our data?”

Despite the difficulties he and his colleagues have faced along the way, Blair remains fully committed to P4P. “Once you get going with it, that’s what keeps you going. It simply wins all the way around. It’s the right thing to do, so people continue to embrace it more strongly all the time.”