Medicare Compliance & Reimbursement

Most payers feel system must be mandatory to work.

MedPAC, private insurers, CMS, many health-policy analysts, and even members of Congress are endorsing pay-for-performance (P4P). In general, people who pay for health care see pay-for-performance as a way of directing $2 trillion in annual U.S. spending toward care that has high value and is delivered efficiently.

Would P4P be mandatory? Of course, say payers. Otherwise, those who can't or won't meet standards simply wouldn't play, and determining whether their care delivers adequate value for the dollar would be impossible.

Yet to be convinced, however, are many providers. For example, the American Medical Association lays out its P4P principles in a new set of guidelines. The document's kicker: "Physician participation in any [P4P] program must be completely voluntary." Efficiency Measures Not Yet Set MedPAC is not currently recommending the next step - paying physicians based on whether they deliver care efficiently.

However, it is recommending that CMS track claims data and report confidentially to individual docs their levels of resource use, and how they compare with other doctors in this regard.

"Physicians would then be able to assess their practice styles, evaluate whether they tend to use more resources than either their peers or what evidence-based research (when available) recommends, and revise their practice style as appropriate," says the March report.