[ Diabetes Type 2 ]

Pay-for-Performance

The goals of clinical interventions in diabetes are to improve not only medical outcomes but health status and health-related quality of life (HRQOL) as well. The aim of this project was to determine if there was any relationship between psychological characteristics and glycemic outcome in a diabetes management program. Design: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. Modest weight loss can significantly improve quality of life for middle-aged and older adults with type 2 diabetes, yielding benefits such as greater ease in performing daily tasks, reduced pain, greater mobility and a better state of mind, according to a review of findings from the Look AHEAD study. Performance measures for diabetes have been in place since the late 1990s (Murphy, Chapel, & Clary, 2004). The outcome measures used were the changes in scores on the self-completion instrument for symptom level, physical function, energy, depression, psychological distress and barriers to activity, HbA1c, non-fasting serum cholesterol and the body mass index (BMI). The mean (standard deviation) HbA1C (%), LDL-C (mg/dL) systolic blood pressure (SBP) (mmHg), and diastolic blood pressure (DBP) (mmHg) were 7.6 (2.0), 107.3 (31.5), 134.3 (20.8), 79.5 (11.0), respectively.

If these outcomes are not achieved, additional action is required, an approach not included in previous promulgations of guidelines for diabetes care. This study is also investigating the prevalence of voluntary physician use of the DMF embedded within the EHR, and determining the effect of DMF use on patient outcomes. The project used an observational study design with primary care practices that underwent a staggered implementation of a commercially available EHR. The primary outcome measure is the first occurrence of a composite cardiovascular outcome, which consists of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke, and hospitalization for angina. The AEP identifies improvement of lower limb strength as a treatment goal. The amount of improvement was consistent with what occurred nationally during the same time period. GM, SS, SG and GV revised critically and approved the manuscript.


condition specific PRO and the needs of the target population (vulnerable populations, low literacy, language and culture, functional abilities). The Freedom of Information office address is available on the Agency’s Web site at http://www.fda.gov. In the demonstration, doctors in 10 large physician group practices received bonuses if they achieved lower cost growth than local controls and met quality targets. The researchers found an improvement in quality but modest reduction in the growth of spending for most Medicare beneficiaries. Cost reductions were greatest for the 15 percent of patients who were dual eligibles, typically low-income people who qualify for both Medicaid and Medicare and who often have complex, chronic conditions. Payer-Provider Controversy: Despite limited evidence of effectiveness, pay-for-performance remains popular among policy makers and public and private insurers as a tool for improving quality of care and containing health care costs. Supporters of pay-for-performance point out that their primary goal has been measuring the quality of care and motivating providers to improve it.

The element of lowering cost has been included only recently in many of these arrangements. Now, supporters say, measuring both quality and cost is important, in part to ensure that quality doesn’t decline even as costs are lowered. Some providers, however, have tended to be skeptical of pay-for-performance arrangements. Although they don’t disagree with the need to focus on quality improvement, they are concerned that the underlying goal of pay-for-performance is cost containment at the expense of patient care. HbA1c) was due, none of these systems could further classify that patient results were at evidence-based goals or not, and no prompts were provided to providers regarding how therapy could be intensified for patients to achieve their clinical goals. Another issue for providers is the cost of adopting the health information technology needed for data collection and reporting. The American Academy of Family Physicians has stated that pay-for-performance incentives must be large enough to allow physicians to recoup their additional administrative costs as well as provide significant incentives for quality improvement.

Safety-Net Providers: Serious concerns have been raised about the impact of pay-for-performance approaches on poorer and disadvantaged populations. You need to be sure that the timing on these questionnaires is the same for all questionnaires and that the visits do not overlap. A study by Alyna Chien at Weill Cornell Medical College found that medical groups caring for patients in lower-income areas of California received lower pay-for-performance scores than others. The reasons were attributed to serving patients who had both language barriers as well as limited access to transportation, child care, or other resources. Similarly, a study by Jha and colleagues of costs and quality in US hospitals found a group that consistently performed worse on both quality and cost metrics and that cares for proportionally greater numbers of elderly black and Medicaid patients than other institutions. Many of these hospitals also have low or zero margins. In general, guidelines for quality care of individual patients are used as the theoretical underpinning to develop population-based quality measures.

Another analysis of Medicare data by Kaiser Health News showed that hospitals that treat large numbers of low-income patients will be hit especially hard from penalties for having overly high ratios of avoidable hospital readmissions. Safety-net hospitals argue that their higher readmission rates reflect their patients’ poor access to physicians and medications. CMS argues, on the other hand, that many safety-net providers outperform hospitals that do not treat significant numbers of low-income patients. This premise is supported by a recent study by Yale researchers that found similar mortality and readmission rates between safety-net and non-safety-net hospitals.

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