Pay for performance (P4P) means that a healthcare practitioner is given extra monetary incentives after completing a successful clinical procedure. Hypertension means that the force of the blood against artery wall is high. As a result, it leads to blood pressure which is a condition that many patients experience. Healthcare organizations have P4P plans and it gives motivation to employees working in clinics and hospitals. This presentation recommends solution when various P4P proposals are provided between insurer and a healthcare organization.
Summary of the Case
In the case study, Chris Hebert is the Managing Director who is responsible for coordinating ambulatory hypertension care at Cleveland Clinic. Hebert has specialized in cardiovascular care and the clinic has trusted him with the services (Kovner, McAlearney & Neuhauser, 2009). While in the clinical duties, Hebert comes across an insurance firm that wants his information and expertise advice on the P4P for hypertension care (Kovner et al., 2009). There are three proposals in the measure which play a role in determining the kind of option that would be considered.
First, the measures propose a pay of bonus for patients who end the year with blood pressure of 140/90 (Kovner et al., 2009). Secondly, payment of bonus for those who improve after a year under care. Lastly, processing of measures only for performance. Hebert realizes that the first and third options would be compatible with a patient who improves blood pressure from 170/90 to 150/80 (Kovner et al., 2009. The third option would work for that matter if the patient is engaged with multiple processes such as calls at home.
Hebert should have at least one recommendation to the insurance firm concerning the P4P measures. The suitable measure in this case is the second proposal; pay a bonus if an individual’s blood pressure has improved after a completing a year under medical care. That must be accompanied by recorded changes in medication so that a physician can justify their role in the care management (Ball, 2016). The reason why this proposal would work for hypertension care is because it will drive a clinical officer to make efforts that can improve the condition after a given period of time.
If patients were paying out of pocket, it would make a significant difference in blood pressure since clinical officers would be highly motivated to think critically on the examination of diagnosis, the prescription formulas and also combating methodologies. On the other hand, patients paying out of pocket might also influence if an individual would be reimbursed later depending on the kind of terms and conditions laid concerning the same (Ball, 2016). However, the model would be challenging for people who have general monetary problems due to poverty, lack of resources among other issues.
Hebert opinion would change if that was his whole medical group’s incentive plan. First, it is important to note that the incentive plan would mean Hebert would be given a lump-sum cash payments after a set period. Therefore, basing on what might be efficient and applicable, the he would have been satisfied by the provisions provided by the insurer (Morgan, Kelley, Guyatt, Johnson & Lavis, 2018). The fee-for-service payment is uncertain as there are determining factors such as lifestyle for patients, measurement mistakes and other reasons.
The expected outcome for the case would depend on Hebert’s opinion and decisions. Since he is supposed to give recommendation based on general improvement of blood pressure levels for the employees, the insurer would agree or disagree based on the satisfactory factions that Hebert presents. However, since Hebert has notable reputation in cardiovascular care, it is likely that the company would adopt his preferred measure (Kovner et al., 2009). Therefore, the insurer will have a plan under guidance of the expert such as a comprehensive recording book or channel to show the blood pressure levels and the consistency of the care professional in driving the matter to the required level.
In the P4P measure chosen, stakeholders would include three parties. First, the patients who will be seeking to combat cardiovascular issues in their preferred clinic. The second stakeholder is the insurer, who is tasked with providing the payment to the clinician after a series of clinical processes concerning hypertension. Third stakeholder is the care professional, in this case Hebert, who shall determine the course of action for the other parties (Kovner et al., 2009). If Hebert performs desirably, the patients would be willing to engage him in the clinical duties. Similarly, if he performs well more so concerning the improvement of the condition, the insurer will be willing to reimburse accordingly.
Under the proposed measure as discussed in the recommended solution, there shall be some limited chances concerning various factors that are evident in the case. First, the proposal means that if a patient’s blood pressure does not show improvement or deteriorates within a year of clinical prescription, then Hebert will not receive his bonus payment (Morgan et al, 2018). It is hard to regular on the outcome since some patients have tendency of refraining from prescribed processes and procedures during a care. The second limitation is that in case there is no medical record of screening diagnosis, even when performed, and the blood pressure has improved, Hebert will not qualify for the bonus.
From the case study, Chris Hebert had a dilemma in choosing among the P4P measures provided by an insurer. The presentation has recommended that Hebert should focus on payment after a patient’s blood pressure improves after a year under care. However, there must be clinical recordings that show he is involved in the care coordination for individuals with hypertension. The proposal is limited since it can lead to no payment if the patient does not show improvement after one year when they start the care.
Ball, W. (2016). Pay-for-performance: Using healthcare economics to improve criminal justice. SSRN Electronic Journal, 7(21), 22-27. doi: 10.2139/ssrn.2765599
Kovner, A., McAlearney, A., & Neuhauser, D. (2009). Health services management (Chap. 9). Chicago, Ill.: Health Administration Press.
Morgan, R., Kelley, L., Guyatt, G., Johnson, A., & Lavis, J. (2018). Decision-making frameworks and considerations for informing coverage decisions for healthcare interventions: A critical interpretive synthesis. Journal Of Clinical Epidemiology, 94(56), 143-150. doi: 10.1016/j.jclinepi.2017.09.023