Wellmark's P4P program: Collaboration on Quality

Wellmark has begun enrolling physicians in a pay-for-performance (P4P) program covering diabetes and hypertension care, as well as generic drug substitution, in Iowa and South Dakota. I may write a brief history of P4P at some point, but for now it should be sufficient to note that P4P has been around for years now. The idea is simple: pay physicians whose patients receive care appropriate for their condition, where "appropriate" is defined by a standards body or the organization cutting the checks. I realize it may seem odd to most, but the interesting part of the Wellmark program is that it also takes into account clinical outcomes rather than just procedure.

The key to Wellmark's program, and what makes it different from the Regence plan in Washington, is its sharing of medical information between Wellmark and participating physicians, Andringa said. By doing this, it uses both clinical data, which measures how often procedures or tests were performed, as well as outcomes data that indicates how patients' health improved.

Clinical outcomes have historically been very difficult to track outside of large, integrated group practices. Insurers generally only have claims data or separate reporting from which to work, blunt instruments at best, while independent standards bodies are fortunate to have workable data at all. Enter MDatacor, Wellmark's partner in this endeavour and the maintainer of the database to which participating physicians will contribute and which will allow for the type of analysis required to bring clinical outcomes into the payment equation.

Of course, much like Consumer-Driven Health Care (CDHC), the goal of P4P is behavior modification with the end result of lower medical cost trends. Also much like CDHC, however, very little is known about the impact of P4P on very relevant issues such as clinical outcomes. Due to the data collection issues mentioned above, data is often only available on the specific measures used to set reward amounts which means we mostly know that P4P increases physician compliance with standards to some degree. Even then, despite the fact that the maximum payment is roughly 10% of the average physician's annual income, the bar for success is set very low:

Andringa said the program has already "raised the bar" of care by improving both the number of people receiving recommended tests as well as measures of their medical outcomes. In 2005, for instance, just 18 percent of Wellmark-covered diabetic patients had received all four recommended annual tests; in 2006 that average increased to 23 percent.

It's also worth mentioning that not all physicians are happy about P4P initiatives in general. While the income boost is often appreciated, other carriers have been using the data gathered to exclude providers from their PPO networks. Wellmark has pledged not to do that, but is discussing offering discounts to members who choose to use high-performing providers.

---

Related links - Terminology

---