QUALITY: Do we need national standards for pay-for-performance?

A couple of weeks back there was an interesting signal that something that’s been debated by policy wonks for some time may be impinging beyond the fringes of the real world of health care. Jack Bovender, CEO of HCA the biggest for-profit hospital chain called for Congress to create standards for pay-for-performance programs. Meanwhile the Leapfrog Group, the employer group that’s been pushing P4P, has created a web site to help y’all keep up with the multiple P4P programs out there. (Here’s the press release).

So it seems that these programs are getting enough attention outside the sideshow health care worlds of California and Massachusetts, that HCA–which doesn’t have any facilities in those states–thinks that it needs someone to regulate and standardize the myriad of programs that, as a major provider, it’s going to have to deal with. In general I’m a fan of standardization in health care. The Dartmouth folks have shown that there’s far too little standardization of care delivery, and P4P programs are in some ways intended to reduce that practice variation. However when we hear calls for standardizing the process and demands for Congressional oversight, we should be very cautious. Firstly, P4P is very new. We don’t really know what works and Medicare (by far the most influential national payer) has yet to start its much vaunted demonstration projects in P4P. So trying to regulate the "answer" is way premature. Secondly, when you hear of a big player like HCA wanting regulation, that usually means that it believes it can do better influencing (or taking advantage of) the regulators than it can working with payers in the open market. And, let’s face it, HCA’s track record in that arena is not exactly full of sweetness, light and innocence.

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