There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).
Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.
Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)
As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.
Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.
For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.
As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.
Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.
Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/