Pay for Performance: Rationale and Potential Implications for Urology

Abstract

Pay for performance represents a new paradigm for physician reimbursement based on the value based purchasing of health care services. Government and private payers have expressed an interest in moving toward this system with several pay for performance programs already in place. The rationale behind this initiative and what it means for the practicing urologist are discussed. MEDLINE and Internet based research focusing on the topics of health care quality, measures used to implement pay for performance, and private and public sector experience with pay for performance to date were reviewed. Health care quality can be assessed through 3 types of measures, including structure, process and outcome. Structure measures involve the environment where services are provided, whereas process measures capture how a particular provider delivers health care. Outcome assessment involves the results of the services provided. These measures are best used when they are used in coordination with each other, and when they are risk adjusted. Most pay for performance systems in use today are based on these measures. However, there are little data that show whether this reimbursement paradigm actually improves the quality of heath care provided. Many questions remain regarding the implementation of a pay for performance system in the field of urology. Government and private payers are motivated to implement pay for performance. However, specific evidence based metrics for urology that fairly and accurately define quality are currently lacking. Given that implementation of a nationwide pay for performance system appears to be inevitable, urology involvement in the development and implementation of these health care quality metrics is essential.