Medicare pay-for-performance dilemma: Who gets the bonus?

Experts say the program needs to focus on greater care management by physicians before quality payment can work well.

By David Glendinning, AMNews staff. April 2, 2007.

Washington -- Medicare's march toward implementing physician pay-for-performance may run into a brick wall when federal officials get down to the job of determining which doctors should be rewarded when things go well, according to a recent study.

The leading pay-for-performance model involves looking back at medical claims data to identify which physician is primarily responsible for a patient's care and then to measure the physician's performance based on predetermined quality measures, said Hoangmai H. Pham, MD, MPH, a senior health researcher at the Center for Studying Health System Change, a Washington, D.C., policy research organization.

In an attempt to determine how readily Medicare could handle this task, Dr. Pham and several colleagues selected about 8,600 physicians from one of the center's past surveys and analyzed their Medicare claims from 2000 to 2002 for roughly 1.8 million beneficiaries to "assign" each patient to individual doctors.

The study, which appeared in the March 15 New England Journal of Medicine, concluded that this process would not be easy for Medicare. The typical beneficiary during the course of a year saw two primary care physicians and five specialists working in four different practices. About one-third of the seniors changed their main doctor from one year to another.

Seniors with certain chronic diseases or multiple conditions had longer lists of physicians, with typical beneficiaries in some categories seeing 10 or more doctors in a given year.