Clinical Geriatrics

We’re all hearing a lot right now about “pay for performance”—programs that offer physicians and other health care providers financial rewards for meeting certain quality or cost-effectiveness standards. Private insurers started introducing pay-for-performance (P4P) programs in the 1990s. These days, “P4P” is making headlines because efforts to introduce it into Medicare are rapidly gaining ground.

An array of policymakers and stakeholders, including The Centers for Medicare & Medicaid Services (CMS), Congress, nongovernmental organizations, and medical societies are involved. This month, CMS will roll out its nationwide Physician Voluntary Reporting Program, a P4P preview that offers physicians the option of giving CMS information about the care they provide to Medicare beneficiaries and getting feedback regarding their performance. (Look for more information on the CMS Voluntary Reporting Program at www.americangeriatrics.org and in upcoming columns.) Just a year ago, CMS launched its first nationwide P4P demonstration in 10 large practices that will be eligible for rewards for meeting specified standards for preventive and chronic care.

As this issue of Clinical Geriatrics went to press in mid-December, Congress was also considering legislation concerning P4P (readers are encouraged to visit www.americangeriatrics.org for an update on congressional action). Just a few weeks prior to an expected vote, the Institute of Medicine (IOM) issued a report calling for a comprehensive and universal system for measuring and reporting the quality of care health care professionals provide. Such a system is necessary if P4P policy is to effectively improve health care quality, the IOM noted.

The way policymakers see it, P4P will improve both the quality of care and enhance cost-effectiveness—a top priority as they try to contain Medicare spending. But P4P carries real risks too. Unless P4P policy is carefully drafted, in a non-budget-neutral manner, for example, it could create disincentives for some providers. Ultimately, this could limit access for patients—especially for those with multiple, interacting, complex medical problems.

For this and related reasons, the AGS and other medical societies have stepped up their involvement as efforts to incorporate P4P into Medicare have gained momentum. As AGS Board Chair Meghan Gerety, MD, recently put it, “we felt strongly that it was in our best interest to try to participate in this process—to make it work the best way possible for geriatrics—rather than to fight it.”

For well over a year, AGS leaders and staff have been meeting regularly with key CMS and congressional staff to lobby for P4P provisions that will ensure high-quality care for older Americans. Last year, the AGS drafted the “American Geriatrics Society Pay for Performance Proposal,” which emphasizes that P4P quality measures must assess the care of all Medicare beneficiaries, including the “old-old,” those with multiple chronic illnesses, and the frail. The proposal calls for measures that have been tested among vulnerable older adults, and measures that recognize the needs of end-of-life patients. And it advocates using RAND’s Assessing Care of Vulnerable Elders (ACOVE) measures for falls, cognitive screening, functional assessment, end-of-life counseling, osteoporosis, and other health problems common among the elderly. The ACOVE measures, created by RAND with support from Pfizer, Inc., are a set of evidence-based indicators that measure the quality of care provided to older adults with 22 common geriatric conditions. Inclusion of such measures would help ensure that the care that geriatricians and others provide for frail patients and for patients with multiple comorbid chronic conditions would be appropriately evaluated by P4P programs.