P4P Quality

Clinician-Directed Performance Improvement is the best way to improve quality…why won’t payers use it?

Goitein (2020) argues that Clinician-Directed Performance Improvement is the best way to improve quality. I agree. This approach empowers physicians and other health care professionals to identify areas for improvement and work on those.

Clinician Directed Performance Improvement (CDPI)…had its origins in 2013, when a group of physicians requested support for a physician-led quality program and the administration agreed to pilot one in the intensive care unit (ICU). There were rapid improvements in ICU clinical outcomes and lowered costs during the pilot program, and in 2015—with the leadership of a new chief medical officer and a start-up grant from a community nonprofit organization now called Anchorum St. Vincent (half-owner of Christus St. Vincent)— the program was expanded to the rest of the hospital.

What is CDPI? There are a few key components to consider:

  • Clinicians need paid dedicated time for quality improvement. If the organization does not dedicate resources, it will be considered an afterthought.
  • Give clinicians training. While clinicians are medically trained, they may not be trained in performance improvement or health services research protocols. Additionally, data entry or other types of administrative support is key.
  • Let clinicians pick their quality program. Giving clinicians autonomy to pick their quality project increases clinician buy-in and investment in the outcomes or the quality initiative.
  • Link quality to financial benefits. Quality must lead to better financial outcomes for the health system either through lower costs, bonus payments from payers, or increased market share/reputation.
  • Development management structures to operationalize. Pilot studies/initiatives are useful, but there must be a mechanism to implement successful quality initiatives into the organization broadly.

CPI has a number of advantages over the current system of payer-driven quality-improvement where pay-for-reporting and gaming are rampant.

Yet, payers are unlikely to be a fan of CDPI. Why?

  • Payers may see paid dedicated time for quality improvement as paying for nothing. It would be difficult for payers to verify that the time has been done directly.
  • Training on quality improvement is helpful, but if payers mandate this it may be seem as a bureaucratic box to check rather than something important to clinician’s organization.
  • Further, payers will care most about how cost, common conditions that increase cost. They will be less willing to let clinicians pick their program if they are paying for their time. Additionally, financial incentives are not aligned. For instance, health systems may want quality initiatives that shorten length of stay, but because payers generally pay per admission (through DRGs), they would care less about quality initiatives that affect length of stay.

There is some cause for hope. Goitein (2020) found that about one-third of the CDPI initiatives targeted metrics currently measured by payers. Additionally, CDPI showed dramatic, rather than gradual changes in quality once initiatives were implement. In short, CDPI has much promise, but with the current health care system drive largely by third-party payment, I am skeptical that payers would be interested in this type of innovative approach to quality improvement.


Leave a Reply

Your email address will not be published. Required fields are marked *