Employers to pay physicians for quality care

Bridges to Excellence, a program doctors helped develop, is one of the biggest corporate pushes to increase quality and decrease costs.

By Mike Norbut, amednews staff. April 28, 2003.

Some of the nation's biggest employers are ready to hand thousands of dollars to physicians -- if they meet certain quality standards.

The employers are working through a nonprofit organization called Bridges to Excellence, a pay-for-performance project. The organization will pay individual doctors with funds from participating companies and a $330,000 grant from the Robert Wood Johnson Foundation. Initially, the project is focusing on rewarding physicians located in Boston, Cincinnati and Louisville, Ky., $100 per patient for meeting standards for quality diabetes care, and physicians in Boston will receive $55 per patient for installing processes to reduce errors and improve quality.

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The per-patient numbers cover those patients employed by participating companies. So far, Procter & Gamble, Humana, Ford Motor Co., General Electric, UPS and the Cincinnati Children's Hospital Medical Center have signed up for the diabetes program, while Verizon Communications and GE are in the physician office program. Several health plans that were involved in creating the program also will help promote the program to their member physicians.

The pilot cities were chosen based on where employees of participating companies were located; the program may be expanded as more employers sign up. The program also plans an effort aimed at cardiac care.

The project is a considerable stepping up of pressure by major payers to increase quality, especially through the use of standards and electronic medical record technology, yet saves money in the process. Bridges to Excellence touts that under the diabetes plan, a company can save a net of $175 per year per employee.

However, the program believes that physician involvement is key to that success, so not only are physicians being rewarded financially, but they also had a say in the design of the program.

Physicians in the pilot project will receive $100 per patient for meeting diabetes quality standards.

Partners Community Healthcare in Boston, the Lahey Clinic in Burlington, Mass., and the Cincinnati Children's Hospital Medical Center helped shape the program and its standards.

"This program recognizes that physicians are human beings doing their best," said Thomas Lee, MD, chief medical officer of Partners Community Healthcare. "You can't reduce error rates more by just getting smarter or by working harder. You need the systems to help you. This will reward physicians for making investments in systems."

AMA President Yank D. Coble Jr., MD, applauded the effort to boost quality, but pointed out several studies that discuss the difficulty in developing pertinent and reliable quality measures for individual physicians.

"It can be so variable in terms of severity of illnesses," Dr. Coble said. "If you're caring for a diabetic population in Miami, it's going to be different from a diabetic population in New York or at Mayo Clinic."

While companies have collaborated on projects like the Leapfrog Group, which is dedicated to improving patient safety through setting quality guidelines, rarely do employers enter the fray with such a financial stake.

But employers said it makes sense, especially when their health insurance premiums continue to rise and their employees continue to miss work because of chronic conditions, costing them millions of dollars.

Putting up some money

Physicians will be paid on a quarterly cycle, and the first checks will be cut in late May or early June, said Francois de Brantes, program leader for health care initiatives for General Electric and coordinator for Bridges to Excellence. The checks will show which companies are paying the bonuses, de Brantes said.

Bridges to Excellence is the latest in what is becoming a long line of quality bonus programs. Last fall, the Integrated Healthcare Assn. announced a plan in which six of California's largest insurers agreed on a set of criteria to rate physicians and pay large medical groups as much as $150 million. However, some physicians have remained skeptical of an idea that is being pushed by HMOs.

Physicians will receive $55 per patient for using error reduction and quality improvement processes.

While the IHA plan is more general in scope, Bridges to Excellence will have three specific areas of focus.

The Diabetes Care Link program, which will initially start in Boston, Cincinnati and Louisville, Ky., will be modeled after the process-and-outcome criteria laid out in the National Committee for Quality Assurance's Diabetes Physician Recognition Program. Allowances will be made for physicians who care for a sicker population, de Brantes said, though details were not provided.

Physician Office Link, which will reward physicians for investing in clinical information systems that can help track patients' health over time, will start in Boston. The program will pay physicians for demonstrating they have established systems to promote ongoing care, like computer system upgrades, care management and patient education programs.

Details of the third program, Cardiac Care Link, are still being developed, though program organizers said the design would be similar to the diabetes care initiative.

Bridges to Excellence has several new twists, but how it attracts physicians remains to be seen. Beau Carter, executive director of Integrated Healthcare Assn., wondered if the per-patient amounts offered would be enough to get physicians' attention.

It depends on how many patients you see from participating employers, said Judith Melin, MD, an internist and medical director of the Lahey Clinic. If employers buy into the idea, the value to the individual doctors may increase, she said.

Some physicians may simply like the idea of an extra reward for work they're already doing. "We're rewarded by attracting more patients and getting bonuses from health plans, but those go pretty unrealized," said Stephen Pohl, MD, a Lexington, Ky., endocrinologist who has been a recognized NCQA diabetes physician for several years. "Once something like [Bridges to Excellence] comes along, we're ready to rock and roll."