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Homework answers / question archive / Read A New Pay-for-Performance Contract - Case Study and respond to the question below
Read A New Pay-for-Performance Contract - Case Study and respond to the question below.
Case Study: A New Pay-for-Performance Contract
An eight-member primary care medical practice signed a new contract with an insurance company. The previous contract had paid the practice an average of $90 for each office visit, and the practice had the opportunity to earn an extra $10 per patient, on average, if certain quality measures were met. Over the previous several years under that contract, they had been recognized as a level-3 PCMH, which had earned them an additional $3 per patient. The practice used the money to hire a nurse and to close quality care gaps.
The members of the practice had met all of the quality measures and had
successfully maximized their earnings.
Under the new contract, the members agreed to accept a lower aver-
age payment of $80 per office visit but hoped to offset that drop by maximizing the new quality payment program, which could earn them an extra
$30 per patient. Unfortunately, the insurance company did not renew the
extra payments for being a PCMH, stating that such status was now a basic
expectation for all practices in the network. Nonetheless, the new contract
gave the practice an opportunity to earn more money overall if it was suc-
cessful in meeting its quality objectives. The members estimated that the
practice would earn less money over the next year, because of the drop in
payments per visit, but could earn more money when the quality results
were tallied at the end of the year, if the practice performed well.
To maximize their chances of success, the practice worked with its
EHR vendor to pull data reports from the system, helping to monitor the
practice's performance on quality metrics and to identify specific patients
who had a gap in care (e.g., patients who needed to have a test completed).
A specially trained medical assistant would then use the reports to call
patients, briefly explain to them what was needed, and arrange for the test
or study to be completed. A provider would write the order, and the medical
assistant would make sure all necessary paperwork was completed.
The practice developed a workflow in the EHR that would flag patients
with a gap in care so that the appropriate action could be initiated imme-
diately by the front desk or medical assistant and quickly approved by the
provider when the patients arrived for office visits. Under this approach,
office staff were asked to work "at the top of their license" and felt that they
were an integral part of the healthcare team. The approach also allowed
providers to focus more on making the complex medical decisions they
were trained to make.
A practice report card was developed to track performance and sup-
port communication among the staff and providers. The report card was
populated with data pulled from the EHR for each metric that was being
tracked, and the data were directly linked to the goals stated in the insur-
ance company contract. The report card was updated on a regular basis
and shared at each monthly practice meeting, when everyone gathered to
discuss current issues. Any metric that was not meeting the performance goal
was discussed in detail, and action plans for improvement were developed.
The staff then used Plan-Do-Study-Act cycles to fix any problems, with a
follow-up report at the next monthly meeting.
