Pay-for-performance. The challenge of performance evaluating in health care

Abstract

The healthcare system has been proved unsustainable leading to an unprecedented crisis. It has been argued that the current reimbursement model to healthcare providers is one of the responsible for this crisis. On the one hand, the prospective reimbursement system (i.e. salary and capitation) stimulates under treatment and risk selection, and on the other hand, the retrospective system (i.e. fee-for-service), leads to perverse incentives and inconsequent cost practices. Thus, the review of the current reimbursement system model for doctors and others healthcare providers is imperative to start the health system reform as a whole. In this article, a Pay-for-Performance (P4P) model for the health sector will be introduced. It can be associated to any simple reimbursement system and it fits to all market, i.e. hospitals, health plan and public health system (SUS). The P4P model has sounds premises that are patient centered, where the performance indicators are gathers in domains related to the dimensions of quality in health; the measures benchmarks are risk adjusted by patients’ characteristics; and the generated information are easy to understand by the providers. The model enables providers to a self evaluation culture and to quest for excellence through incentives, financial or not, related to their performance. The biggest challenges to implement performance evaluation programs in healthcare are the following: the doctors’ engagement in quality improvement agenda; the paradigm shift of standardization in healthcare; the capability of producing consistent data to build adequate performance measures; and, finally, to avoid the performance evaluations programs traps such as: risk adjustment, empiric models that are not client centered, the imposition of the criteria to the providers, and develop a program just focus on reducing costs.