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Lawrence P. Casalino, Arthur Elster, Andy Eisenberg, Evelyn Lewis, John Montgomery, and Diana Ramos Will Pay-For-Performance And Quality Reporting Affect Health Care Disparities? Health Affairs, May/June 2007; 26(3): w405-w414. [Abstract] [Full Text] [PDF] [Erratum] [Reprints & Permissions]

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Learning from Other Systems

Bradford L. Kirkman-Liff   ( 13 April 2007 )

Technical Infrastructure, Thresholds, And Grading On The Curve Incent All To Excellence

John Haughton MD, MS   ( 16 April 2007 )

It's About Time And Resources

Kevin Fiscella   ( 17 April 2007 )

First Learn To Measure Health Care Disparities

James P. Scanlan   ( 12 March 2008 )

Learning from Other Systems 13 April 2007
Bradford L. Kirkman-Liff, Professor School of Health Management and Policy, Arizona State University Send comment to journal: Re: Learning from Other Systems bradford.kirkman.liff{at}asu.edu Bradford L. Kirkman-Liff	Casalino and Elster's excellent analysis of the potential problems with pay-for-performance incentives in the American health system demonstrates the importance of looking to other health systems for insights into addressing health inequalities in our system. Despite 60 years of universal coverage, health inequalities exist in most European health systems, along socioeconomic and ethnic lines. Many of those systems are also experimenting with various forms of pay-for-performance and public reporting of process and outcome measures. Casalino and Elster mention some of the methods used in the British NHS in their pay-for-performance experiments to address some concerns. Mutual collaboration across borders in examining how health disparities and improved quality can be simultaneously addressed by carefully designed financial incentives should be a priority.
Technical Infrastructure, Thresholds, And Grading On The Curve Incent All To Excellence 16 April 2007
John Haughton MD, MS, CEO DocSite point of care registry and reporting Send comment to journal: Re: Technical Infrastructure, Thresholds, And Grading On The Curve Incent All To Excellence jhmd{at}docsite.com John Haughton MD, MS	Regarding Casalino and Elster's six steps for reducing disparities, I would like to suggest a seventh. P4P programs aimed at reducing disparities should consider the first tier of payment: access to a "good enough" system for patient-level decision support at the point of care and population reporting, perhaps one that can be used in both a paper and paperless office. Practitioners caring for populations with health care disparities may have little money and technical support available for infrastructure. If the provider uses the offered web (for low cost and minimal support needs) system, he or she can keep using it. If the clinic already has a system, then it may get a premium on the other P4P levels. P4P then would be paid out in 3 levels: (1) A reporting/clinical system is available for use to those who do not have one (incents current nonusers). (2) Threshold payments at the basement of acceptable for process/outcomes goal in place. Can have 2 tiers of threshold - top and bottom of "acceptable" (incents even poor performers to reach for something). (3) Highly incent (and evaluate) the top of the curve with payments based on the performance. The group at large may have something to learn from this subset of high performers. Additionally, they may use resources to further innovation, pointing the way to further success (incents the innovators, or at least the ones who effectively execute on the measurement program).
It's About Time And Resources 17 April 2007
Kevin Fiscella, Associate Professor Depts of Family Medicine and Community & Preventive Medicine, University of Rochester Send comment to journal: Re: It's About Time And Resources kevin_fiscella{at}urmc.rochester.edu Kevin Fiscella	I applaud Casalino and Elster for drawing attention to the potential unintended consequences of P4P and quality reporting on health care disparities. All too often, national policies in the U.S. are implemented without regard to their potential disparate impact. The authors indicate that practices serving poor and minority patients are doubly disadvantaged. It's also about time. These practices not only confront a less favorable payer mix and greater patient barriers to adherence, but they also care for patients who require far more time to adequately address their health care needs. The 15-minute office visit scarcely meets the needs of the best-educated and most affluent patients. It is woefully inadequate for patients with limited English proficiency, low health literacy, multiple comorbidities, and complex psychosocial problems. No current risk adjustment system will fix the problem. In terms of remedies, the British experience is instructive. Practices serving poorer patients fared only slightly worse under the U.K. program. But the playing field is far more level in the U.K. than in the U.S. The U.K. health system includes universal insurance coverage and uniform physician payments, focus on primary care, a national system for health information technology, and, most importantly, bonus payments to practices serving underserved communities. In contrast in the U.S., practices are financially penalized through lower Medicaid payments (or no payments) for caring for underserved and uninsured patients. Until U.S. health policymakers and payers come to grips with the truism that socially disadvantaged patients require more, not less, time and that practices serving these patients require more, not fewer, resources, implementation of P4P will only widen the resource divide between practices and the health divide between patients.
First Learn To Measure Health Care Disparities 12 March 2008
James P. Scanlan, Attorney James P. Scanlan, Attorney at Law Send comment to journal: Re: First Learn To Measure Health Care Disparities jps{at}jpscanlan.com James P. Scanlan	The article by Casalino et al. is increasingly cited in articles favoring the inclusion of effects on health care disparities as a measure of performance in pay-for-performance programs. But there is no consensus on how to measure changes in health care disparities over time. Further, as health care improves (with improvement measured in terms of increases in overall rates of receiving appropriate care), the relative difference between rates of receiving appropriate care (one common measure of disparity) tends to decrease while the relative difference between rates of failing to receive appropriate care (a less common measure, but the one typically used by the National Center for Health Statistics and the Agency for Healthcare Research and Quality) tends to increase. The absolute difference between rates (also a common measure of disparity and the one recommended for the Massachusetts pay-for-performance program discussed in the Casalino article) tends to increase as a relatively uncommon procedure becomes more widespread and to decline as a relatively common procedure becomes more widespread. The difference measured by the odds ratio (another common approach) tends to change in the opposite direction of the absolute difference as procedures become more common. Apart from the fact that various measures tend to change in opposite directions as the overall level of appropriate care changes, none of these measures can alone effectively distinguish changes over time that are solely a function of changes in the overall level of an outcome from those that reflect something more meaningful. For a fuller discussion of these tendencies and the way the failure to understand them undermines most health and healthcare disparities research, see, e.g., my: Can we actually measure health disparities? Chance 2006:19(2):47-51: http://www.jpscanlan.com/images/Can_We_Actually_Measure_Health_Disparities.pdf "Can We Actually Measure Health Disparities," presented at the 7th International Conference on Health Policy Statistics, Philadelphia, PA, Jan. 17-18, 2008: PowerPoint Presentation: http://www.jpscanlan.com/images/2008_ICHPS.ppt; Oral Presentation: http://www.jpscanlan.com/images/2008_ICHPS_Oral.pdf "Measurement Problems in the National Healthcare Disparities Report," presented at American Public Health Association 135th Annual Meeting and Exposition, Washington, DC, Nov. 3-7, 2007: PowerPoint Presentation: http://www.jpscanlan.com/images/APHA_2007_Presentation.ppt; Oral Presentation: http://www.jpscanlan.com/images/ORAL_ANNOTATED.pdf; Addendum (March 11, 2008): http://www.jpscanlan.com/images/Addendum.pdf Inclusion of healthcare disparities issues in pay-for-performance programs should await development of reliable means of measuring changes in disparities over time. Journal Review Feb. 16, 2008 (responding to the Casalino article): http://www.journalreview.org/view_pubmed_article.php?pmid=17426053&specialty_id=0 Until these measurement issues are resolved, it would be a serious mistake to encumber what might otherwise be useful pay-for-performance programs with attempts to evaluate effects on health care disparities.