Merging P4P and disease management: how do you know which one is working?

• Published in: Journal of managed care pharmacy 2007-03, Vol.13 (2 Suppl B), p.S7-10
• Main Author: Smith, Allen L
• Format: Article
• Language: English
• Subjects: Cea; Diabetes Mellitus - therapy; Disease Management; Humans; Managed Care Programs - economics; Outcome and Process Assessment (Health Care); Physician Incentive Plans - economics; Quality Assurance, Health Care - economics; Quality Assurance, Health Care - methods; Quality Indicators, Health Care; Radiology - standards; Reimbursement, Incentive; United States
• ISSN: 1083-4087; 1944-706X
• DOI: 10.18553/jmcp.2007.13.s2-b.7

An intervention movement in managed care, disease management (DM), is a system of coordinated health care interventions and communication for populations with conditions in which patient self-care efforts are significant. Another managed care intervention movement, pay for performance (P4P), involves an incentive component in which payment is defined based on meeting specific, previously agreed-upon process or outcomes targets. To explore the various characteristics of DM and P4P interventions, determine how they differ, and explore the differences in results of programs in current practice. In DM, regular ongoing evaluation of clinical, humanistic, and economic outcomes plays a crucial role in reducing costs and improving quality of care. The goal of improving overall patient health in DM is also accomplished by supporting the physician or practitioner/patient relationship and plan of care. P4P initiatives vary more according to the needs and preferences of local providers and plans than do DM initiatives. While DM programs can be implemented without necessarily changing how providers deliver health care, P4P requires new programs and/or systems within the provider sector to improve patient care quality and/or efficiency. P4P initiatives also typically involve the upside or downside risk by physicians/hospitals. Partners HealthCare, based in Boston, features P4P initiatives for inpatient admissions, diabetes, and radiology that have all been met with success. Both DM and P4P initiatives have been successful in managed care. However, in terms of determining whether DM or P4P initiatives are more effective in improving the quality and efficiency of health care delivery, it is simply too early to tell at this time.