Nurse practitioner Hannah comes in on her day off to attend the evening meeting of her primary care group. Since all the providers are paid with a similar compensation plan, the meeting is attended by the physicians and nurse practitioners. The business manager and director of quality also attend.
The practice president, a family physician, opens the meeting: “As you all know, we all believe there should be no surprises at our monthly meetings. You all receive your daily and weekly practice reports of your productivity, quality measures, and citizenship measures. This meeting gives us an opportunity to be sure we understand the connection between the measures of our performance and our pay, and to compare notes so that we may all learn from each other how to achieve best possible performance.”
Each provider pulls up the reports on a tablet computer in front of them. The business manager walks them through each page of the report. Because this is healthcare, they always start with the quality and safety reports, move to the financial report performance, and then to citizenship. Because this is a health system employed practice, the measures tied to pay are the same across all primary care providers, including nurse practitioners and physician assistants.
The business manager reminds the group that not every measure is tied to a financial incentive in their contracts with the various insurance companies, and that this is a deliberate strategic decision on the part of the management and Board of the health system. “Alignment” of clinical performance around the needs of the population the health system serves is possible only if everyone operates with the same incentives. The health system decided to “buffer” the providers from the ever-changing incentives tied to their insurance company contracts. And although most insurance companies tend to link payments to somewhat similar quality measures around chronic illness and certain preventive measures, they are not all the same and often differ from government payers. Hannah thinks, “I'm glad I don't need to play the game of treating patients according to their insurance company rules anymore.”
First, the business manager reviews each of the quality and safety measures. Every provider is identified for their performance monthly and year to date. Each provider can see their individual performance, everyone else's individual performance; they can also compare themselves to the overall practice mean.
Wadee, one of the family docs, comments to Hannah that he is beginning to see his diabetic patients improve their overall control since his team started to enroll everyone with diabetes in the "self-management" course offered at the local college. Wadee became interested in how Hannah was achieving better control in her population of people with diabetes than Wadee was able to do with his team. “It still bothers me a bit to enter the exam room each time and ask the patient which of their goals they are working on, instead of working from my list,” admits Wadee. The patients who have completed the self-management course have demonstrated improved control and decreased their utilization of office visits and emergency room visits by 50 percent.
After a lively quality and safety measures discussion, the financial performance reports come up next. While each provider is rewarded for being “busy,” they are still experimenting with defining what that means. Figuring out how to “weight” an e-mail, telephone call, or video conference with the patient is still vexing the group.
The business manager reminds the providers of another significant adjustment in how they look at their practice finances: the biggest boost to the practice revenue comes from savings in overall health expenditures this year compared to last. Those savings are shared in formulas related to their quality scores. Without the shared savings, the practice revenue would not be adequate to sustain their salaries even at last year's level. The group is encouraged by recent reports that some health systems are achieving reductions in utilization of hospital, specialists, and emergency rooms by over 50%.
Cooley Dickinson Hospital • 30 Locust St. (Route 9), Northampton, Mass. • (413) 582-2000