pay for performance (Full Version)

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aph401 -> pay for performance (May 7, 2008 1:04:28 AM)

this was posted on another forum i frequent (myphysicaltherapyspace) and i wanted to repost it here to get some opinions.
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Hey all,

So in PT school, we got into a heated debate regarding issues of pay for performance, and so I was wondering what other future or current PT's thoughts were on this subject. I thought I would ask the "Students group" because we are the future of the profession, and we can make awesome change agents because we are young and pliable!

Pay for performance is what occurs in the Physician world, where physicians are paid a base salary, and then depending on hours worked, patients seen, and outcomes achieved, could build on that income. This makes a career as an M.D. more risk aversive, but there is more incentives or reward for good work. A majority of physical therapists, I believe, are not working in this pay for performance type model. There is a flat, pre-determined salary based on experience, abilities, etc., which makes a job as a PT less risk aversive, but then it would seem that mediocrity pays the same as over-achievement, and is that what we want for our profession as we are leaping forward to be on a doctoral level? Do you think that transitioning to a "pay for performance" type model would be of benefit to our profession, and if so, what's it going to take to make that transition?

Thanks!



SJBird55 -> RE: pay for performance (May 7, 2008 6:29:20 AM)

It might end up being more of a pay for compliance kind of a thing.

P4P won't easily occur in the PT world.  The main payer that was contemplating P4P was Medicare.  Claim forms do not have the current capability for outcome data.  Dennis Hart presented the information he had with P4P and in all honesty, I liked his concept (a tiered payment system), but it was flawed.  For the Medicare beneficiary population, there truly isn't enough data as of yet to risk adjust AND one of the main programs out there for data collection doesn't have enough categories that do affect this particular population... nor do we necessarily have enough evidence to prove a particular factor IS a factor.  For example... someone in this particular population that is incontinent, has dementia, and is depressed might not achieve the same level of outcome in the same amount of time as someone who does not have those variables.  I believe those can be variables that have an effect on the services we provide, but as of yet there isn't strong evidence that substantiates my belief.  At the same time, there isn't any "quality" standard to meet when it does come to outcomes.  For example... at bare minimum, should every patient achieve at least the minimal clinically important difference?  What if a patient achieves WAY more than, for example, a 10 point change in score (which is supposed to be the minimal clinically important difference)?  What if the patient isn't reliable?  Do we want a system based on a subjective reporting system to determine our effectiveness?  Also, as a whole, the majority in our profession are not tracking outcomes - as a whole group with limited data and no experience in tracking outcomes, we can't be the "experts" in knowing anything about outcomes.  This would mean, in my opinion, if something does come down the pipes on P4P to be a payment system, collectively we are screwed.  There won't be enough of us "experienced" with outcomes to be a voice so that the P4P attempt would be realistic and reasonable and favor our services - I imagine it would be more payer friendly - payers will do anything to not pay.  I doubt that anything will happen any time soon.



PTupdate.com -> RE: pay for performance (May 7, 2008 8:07:23 AM)

I have always been a HUGE believe in this type of system for PT's.  Pay them a base of say $25K, and the rest is all based on productivity.  The only caveat is that they need to be monitored for over utilization.  I have put people on good bonus structures in the past, and it becomes a win win for everybody.

The typical apathetic PT, working for someone elses pocketbook, is not going to take those extra steps needed to generate more business....when they really see nothing in return.  Why put in an extra 10 hours per week just to make someone else rich?  Give them a cut, and you'll be amazed how marketing improves, the clinic suddenly is open later (because those patients that typically want/need to come late are always quickly discharged) and satisfaction/outcomes improve as well.



SJBird55 -> RE: pay for performance (May 7, 2008 11:18:10 AM)

Whoa, Duffy... is performance from a third party payer perspective going to be tied to productivity?  Does a more productive therapist do good work?  How are you evaluating "good" work?

OR am I completely missing the boat and instead of a P4P reimbursement system as P4P is traditionally defined... this P4P idea is instead now meaning an employer type of incentive?



goodlooks58 -> RE: pay for performance (May 8, 2008 1:59:29 AM)

SJ: After 22 years in practise, I seriously believe that patient satisfaction and goal achievement is possible in shorter time resulting in higher productivity. There are no rules or protocols which suggests that a new eval needs an hour or a repeat tx to be 45 minutes. I think we all need to look at the ins. reimbursement scam and smell the POPTS stink around us and take a hard look at what the pt's expectations are from PTs. In an ideal world I should be getting $395 per hour for patient tx and yes, then I will spend 1.5 hour with the pt. and yes, I will get the pt. better and out of the clinic in 2 visits. Lawyers, plumbers, electricians etc.. charge, why not PTs? Why do we have to take crap for medicare and ins. cos with a set price? On a side note: I just found out that an orthopod who used to send a large # of pts. my way, suddenly got a chiro in his office and is doing PT. The bad part is that the ortho's biller who is friend told me that the PT reimbusement to the PT done in ortho office is more than what I get. This really sucks. Why bother going to PT school!



SJBird55 -> RE: pay for performance (May 8, 2008 6:34:40 AM)

goodlooks...
quote:

goal achievement is possible in shorter time
... compared to what?

The time for a new eval is dependent upon the patient walking through the doors... for me, someone with back pain takes longer versus someone with an ankle sprain.  Someone older (like 65+) generally takes a lot longer versus a middle school/high school aged person.  Someone with a chronic condition takes longer than an acute injury.  The biggest problem, especially for someone at the scheduling end of it, is that the scheduler is acquiring registration information and spends quite a bit of time on the phone obtaining that information.  After that occurs, then the scheduler is going to schedule an appointment for the new patient.  Do you want the scheduler also asking detailed, somewhat personal questions to be the one to determine if the eval should be 30 minutes, 45 minutes or 60 minutes.... or do you just want a predetermined amount of time so the scheduler just places the new patient in a slot? Then, if you have the scheduler determine the amount of time required for an initial eval based on screening questions  - what if you actually need more time for the evaluation?  Your first visit is it - game on during that session.  During that session, the first impression is made.  I know I would rather error on having too much time versus too little time.  Besides the fact, for me, the time for an initial evaluation also has treatment time included.  If I have a 45 minute block of time for an initial evaluation and it takes me 15 minutes - well, I provide 30 minutes of treatment.  That is actually the best situation because on that day for that patient I financially win!  :)

In regard to a different payment scheme by third party payers - you could report this to your California association and work on getting equal reimbursement for all practice settings.



JSPT -> RE: pay for performance (May 8, 2008 7:02:33 AM)

(golf clap) for Duffy.  



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