By Jillian Kelly, Tania Marmolejos, and Kristin Botzer

Performance Evaluations Related

To Patient Outcomes:

Con

What is Pay-for-Outcomes Based Care?

Developed by managed care organizations to replace “Pay-for-Performance”

("PTPN’s pay-for outcomes program," 2013).

Recognizes and rewards organizations getting patients better efficiently

("PTPN’s pay-for outcomes program," 2013).

Paying hospitals and providers that meet particular quality measures and

clinical outcomes (Burns, 2011).

Pay for outcomes has become popular with Medicare and Medicaid, huge payers

with a huge patient database that we deal with every day. (Health Policy

Beliefs, 2012)

The Affordable Care Act in place by President Obama has promoted this.

(Health Policy Beliefs, 2012)

What is a Performance Review?

An opportunity to discuss job performance.

(including positive or negative events that may have occurred altering

quality measures)

A time to set professional goals.

A chance to discuss your contribution to the department’s mission.

An opportunity to discuss expectations and accomplishments you have

achieved.

(The University of Tennessee Knoxville, n.d.)

Performance Evaluations Tied to Patient

Outcomes “Tools intended to induce provider behavioral change to foster

performance improvement and add value” (Kurtzman et al., 2011, para. 1).

“Pay bonuses to providers for demonstrated improvements in the quality of care” (Kurtzman et al., 2011, para. 1).

“More than half of commercial health maintenance organizations (HMOs) and state Medicaid programs operate pay-for-performance programs” (Kurtzman et al., 2011, para. 1).

“Medicare is also adjusting its reimbursement rates to reward quality through various incentive programs”(Kurtzman et al., 2011, para. 1).

Consider the comic to the right. How many of us have had days like this? If we were all in it for the money, we would not still be in the profession. Bonuses and incentives based on patient outcomes is unrealistic. We can do everything in our power to appease patients and save their lives, but many times, it just isn’t enough. And at the end of the day, we still deserve to be paid.

Factors Affecting Success

Size of incentive:

Some programs with incentives of $2 per patient have had improved quality;

whereas programs with high incentives of up to $10,000 per practice have had

no improvement in quality (Werner et al., 2011). .

Public Reporting:

Prior research has proposed that public reporting of information about

hospital’s quality of care is what improves that quality. So, since public

reporting and the CMS P4P project launched the same year, it is hard to tell

which one caused the improvement in quality (Werner et al., 2011).

Factors Affecting Success

Availability of Resources:

Hospitals without the resources to invest in changes to improve quality will not succeed in receiving incentives.

EXAMPLE

Staffing and technology are two areas that require maintenance and investment. If hospitals reduce investments during tough financial times, this program will worsen the hospital’s financial grading (Werner et al., 2011).

Lack of consistency:

Studies done thus far have shown that the effects of pay-for-performance have been short lived and in the long run, performance scores were equivocal. (Health Policy Beliefs, 2012)

Other studies done have showed no difference in mortality rates between those participating in a pay-for-performance initiative versus those not participating. (Health Policy Beliefs, 2012)

Harmful Consequences P4P(Pay for Performance) uses a medicalization approach instead of the

recommended holistic approach. This causes excessive uses of unneeded treatments.

EXAMPLES:

- Controlling illnesses such as hypertension and/or hyperlipidemia can lead to unnecessary drug treatments and a greater risk for adverse effects on patients.

- The increase of drug treatment in order to reach targeted patient outcomes for incentive purposes, can lead to an increased in mortality rates.

****Respect for the person rather than the outcome, can easily become vanished in the systems that pay for performance related to patient outcomes. (Siriwardena, 2014).

This leads us to ethical concerns related to Pay-for-Performance…..

Ethical Concerns

If patients are unaware that providers are incentivized to treat

certain illnesses, recommend certain treatments, or perform

certain tasks, this can weaken the TRUST and affect AUTONOMY.

(Siriwardena, 2014).

Think about this: There is such a thing as over-treating a patient. When

healthcare professionals have monetary incentives to promote certain outcomes

and prevent mortality, they may treat patients aggressively. This could be

detrimental. Over using medicine and technology can have negative effects and

outcomes. It could also be dangerous because are patient wishes and desires being

taken into consideration every single time? Are we sure this is what our patients

want? Pay-for-performance could decrease healthcare professionals awareness of

patients emotional and psychological health. Remember we are in this field to

promote health and well-being but sometimes it isn’t about preventing mortality

but promoting patient DIGNITY.

Importance of this Issue on Nursing

According to the Robert Wood Johnson Foundation (2009),

“Nurse leaders and researchers are interested in figuring out how pay for

performance can incentivize nurses to improve patient care and control costs

in all settings, to date pay-for-performance programs have typically focused

on hospitals and physician practices” (p.2).

“Although hospital care is provided primarily by nurses, current

reimbursement formulas ignore the specific, unique services nurses provide

and merely consider nursing as part of room and board charges” (p. 2).

“Experts are concerned about the pressures that pay-for-performance

initiatives will place on institutions already struggling with staffing shortages,

especially those that serve vulnerable populations” (p.3).

Issues with Evaluating Nurses by Patient

Outcomes

Pay-for-performance programs result in financial penalties on nurses

who do not meet the specific goal(s).

Is this fair?! We have all had difficult patients that are impossible to

please or patients who still end up passing. How would you feel if this

resulted in a pay grade decrease?

Pay-for-performance (P4P) is a scheme that has a goal to perform more

efficiently than other organizations, INSTEAD OF to improve overall

quality.

Will providers avoid disadvantaged populations so that their

performance scores do not decrease?

A study done by Alyna Chien at Weill Cornell Medical College observed

that providers caring for patients residing in the lower-income

areas in California, received lower performance scores than others.

*An analysis of Medicare data showed that hospitals caring for low-income

patients will be penalized greatly due to excessive increased ratios of

preventable hospital readmissions.

(Health Policy Brief, 2012)

Issues with Evaluating Nurses by Patient

Outcomes (continued)

Creativity is lost and attention is narrowed in those who receive incentives for

performance and positive patient outcomes.

Healthcare providers who receive financial incentives are distracted from

important duties, by constantly thinking of the reward they may receive or

may not receive from their performance.

Many studies in the USA and India illustrated that high incentives lead to

poorer performance, compared to low and/or reasonable financial incentives.

(Siriwardena, 2014).

Pay-for-performance is ultimately a negative motivator for healthcare

professionals.

It could draw forth the wrong individuals to the field chasing the money and

incentives. The best healthcare workers are those who have the patient at

heart and not the dollar. Those in it for the money do not last and do not

provide the best patient care, instead they are task oriented and lack the

bedside abilities.

Issues with Evaluating Nurses by Patient

Outcomes (continued)

Evidence from behavioral economics propose that monetary incentives are likely to result in WORSE performance.

HOW?

“Choking under pressure”- a well known Yerkes-Dodson law that states, when performance increases with anxiety, a threshold is reached to a

point that destroys performance levels. What does this mean?

Receiving monetary bonuses related to patient outcomes can cause healthcare providers to overthink tasks and problems, which will ultimately lead to worse performance and bad patient outcomes.

(Siriwardena, 2014).

Questions Without Answers

Pay-for-outcomes programs will most likely be expanding nationwide in the future.

HOWEVER……. How can performance improvements last over time?

How large does the payment have to be to produce wanted changes?

How often should rewards be given out?

What consequences will this have on populations who are financially weak and/or that contain greater minority groups?

(Health Policy Brief, 2012)

Should payments go to the individual causing positive patient outcomes or to the entire organization? (Siriwardena, 2014).

Evaluations will need to be long term, to allow for identification of unintended consequences (Health Policy Beliefs, 2012)

Addressing the Opposing Side

Claim: Increases the quality and safety within healthcare institutions.

Implication : “Nurses may need to spend even more time away from patients documenting care. Some studies show that nurses in acute care already spend 30 percent or more of their work time on documentation” (Robert Wood Johnson Foundation, 2009, p. 8).

More time spent on documentation…..is that really what nurses need?

Claim: Will lead to higher quality nursing performance.

Implications: The expectation is that there will be an initial increase in disciplinary action (Osborne, 2014). Nurses are concerned about absorbingblame for occurrences such as hospital-acquired infections (Kurtzman et al., 2011).

Will this cause animosity and lateral violence? Will nurses be afraid to report errors?

Claim: It is a cost saving measure.

Implication: Viewed as increasing the demands on nurses with little effect on reducing turnover or salaries (Kurtzman et al., 2011).

Addressing the Opposing Side

(continued)

Claim: These programs show results.

Implication: A study of the Premier Hospital Quality Incentive Demonstration project showed that hospitals improved their quality of care rates after the implementation of this program. However, this ONLY lasted 5 years.

Is it worth the time and effort for a short term goal? Will nurses be penalized financially for not meeting outcome expectations?

Claim: Paying for quality not quantity is better.

Implication: Defining “quality” of care is hard, almost impossible. Quality of care for one patient in one situation, is totally different to another patient in another situation (Carroll, 2014).

How are insurance companies going to pay healthcare providers based on quality if it is different in every situation? What is their definition of quality? Does every payer have their own definition?

Addressing the Opposing Side

(continued)

Claim: Refusing to pay for hospitalizations that have hospital acquired

pneumonia, UTI’s, etc. will reduce the rate of such infections.

Implications: In 2008, Medicare thought that this would improve

performances in hospitals and improved care but that did not happen. This

policy has little to no measurable effect. (Carroll, 2014)

Measurements used in determining pay did not account for things out of the

providers control such as: environment, income, housing, and education.

This means that hospitals in cities or low economic settings, that care for

the poor, are penalized because the measurements do not account for items

out the hospital and providers hands. (Carroll, 2014)

The End

References About a Nurse [Cartoon]. (n.d.). Retrieved from

https://www.pinterest.com/pin/10062799140673001/

Burns, J. (2011, September). At long last… pay for outcomes starts to replace

pay for performance. Managed Care. Retrieved from

http://www.managedcaremag.com/

Carroll, A. (2014). The Problem With ‘Pay for Performance’ in Medicine. The

New York Times. Retrieved from

http://www.nytimes.com/2014/07/29/upshot/the-problem-with-pay-for-

performance-in-medicine.html?_r=0&abt=0002&abg=1

Getty Images. (2014). Stop the defensiveness; come up with a plan to address

your shortcomings. [Photograph]. Retrieved from

http://www.usatoday.com/story/money/

Green Career Central. (2014) Feeling Boxed In By Your Career? There's a Way

Out. [Photograph]. Retrieved from http://www.greencareercentral.co

Health Policy Brief: Pay-for-Performance. (2012). Health Affairs. Retrieved

from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78.

References Kruse, K. (2012). Performance appraisals: 4 reasons why they must be

abolished. Retrieved from http://www.kevinkruse.com/

Kurtzman, E. T., O’Leary, D., Sheingold, B. H., Devers, K. J., Dawson, E. M., &

Johnson, J. E. (2011). Performance-based payment incentives increase

burden and blame for hospital nurses. Health Affairs, 30(2), 211-218.

http://dx.doi.org/10.1377/hlthaff.2010.0573

Manary, M. P., Boulding, W., Staelin, R., & Glickman, S. W. (2013). The patient

experience and health outcomes. New England Journal of Medicine, 368, 201-

203. http://dx.doi.org/10.1056/NEJMp1211775

Mt. Vernon Nursing & Rehab Center. (2015). Long-term care [Photograph].

Retrieved from http://www.mvnrc.net/services/

National payers adopt PTPN’s pay-for outcomes program for physical therapy

and occupational therapy services. (2013). Managed Care Outlook, 26(4), 1-5.

Retrieved from http://www.ebscohost.com/

Nurses, be stress free in 10 seconds. (Photograph). Retrieved from

http://www.nursetogether.com/

References

Osborne, K. (2014). Employers welcome guidance on performance-related pay systems. Nursing Standard, 28(42), 14-15. Retrieved from http://www.nursing-standard-journal.co.uk/

Robert Wood Johnson Foundation (Ed.). (2009). Perspectives on pay for performance in nursing: Key considerations in shaping payment systems to drive better patient care outcomes. Charting Nursing’s Future. Retrieved from http://www.rwjf.org/en.html

Siriwardena, A. N. (2014). The ethics of pay-for-performance. Quality In Primary Care, 22(2), 53-55.

The University of Tennessee Knoxville. (n.d.). Performance Evaluation. Retrieved from http://hr.utk.edu/performance-evaluation/

Werner, R., Kolstad, J., Stuart, E., & Polsky, D. (2011). The effect of pay-for-performance in hospitals: Lessons for quality improvement. Health Affairs,30(4), 690-698. Retrieved from http://content.healthaffairs.org.pacollege.idm.oclc.org/content/30/4/690.full.

Color Key

Jillian Kelly – Blue

Tania Marmolejos – Black/Red

Kristin Botzer - Green