Implementing Pay-for-Performance in the Neonatal Intensive Care Unit

Abstract

Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-forperformance and the state of quality measurement science, experimentation with pay-forperformance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting. Keywords pay-for-performance programs; quality improvementLarge deficits in quality of care remain more than half a decade after the Institute of Medicine (IOM) provided a blueprint for improvement. 1 In neonatology, there is persistent unexplained variation in health care delivery and outcomes. [2][3][4][5][6][7][8] To date, quality improvement (QI) efforts, either locally or as part of collaborative efforts, have had mixed results. 9-17 The broad-based improvement envisioned by health care payers and the IOM has not occurred. (In this article, we use the term "payer" to mean the broad group of employers, purchasers, insurers, and health care plans that pay for health care services directly or indirectly.)

Patient Safety in the NICU

“…Incentives and disincentives 28 Stop payments for hospitals with negative consequences of care or the never events. Reward hospitals with reimbursement incentives.…”

Baby-MONITOR: A Composite Indicator of NICU Quality

“…The development of the Baby-MONITOR followed a formal, stepwise, and explicit process that has been peer reviewed and is widely applied in health and non-health settings. 3,[26][27][28] In previous work, we developed a theoretical framework for the Baby-MONITOR, 4,15 selected measures of quality …”

“…3,4,15 Preliminary steps in the development of the Baby-MONITOR included development of a theoretical framework 4,15 ; expert-informed selection of its measure components 14,16 ; initial data analysis (1) to investigate the completeness of the data, (2) to develop and test adequate measure definitions and restrictions, and (3) to minimize systematic selection and transfer biases; and construction of risk adjustment models. 17 With these building blocks in place, we standardized and risk-adjusted outcomes, weighted the individual components, and aggregated measures to form a composite indicator.…”

Pay for performance in critical care: An executive summary of the position paper by the Society of Critical Care Medicine*

“…Thus, critical care patient outcomes can rarely be attributed to a single provider or even a single group of physicians. Profit et al (41) have proposed that P4P in the neonatal intensive care unit be directed at entire hospitals, units, or groups with financial incentives shared within the entire multi-specialty group. This and other proposals require consideration when implementing P4P for critical care.…”