Incentivizing nursing home quality and physician performance.

Nursing homes (NHs) are under increasing pressure to accurately gauge and improve the quality of care they provide to their residents. Higher patient acuity, demand from consumers and policy-makers, and media reports of inadequate care are providing the impetus for change. In response to these pressures, researchers are devising more appropriate indicators of quality,1 states are creating innovative financial models to reward the delivery of higher quality care, and the American Medical Directors Association (AMDA) is developing strategies to better gauge the performance of NH physicians and medical directors. The interplay of these factors not only has provided new opportunities to impact approaches to quality measurement in the NH but also has rejuvenated interest in measuring the impact of physician performance on NH quality. In this article, we highlight the efforts of one state that is in process of implementing an incentivized model for highquality care that includes physician certification in the model. We end by offering potential solutions to enhancing physician involvement in NH affairs and weaving physician performance into these evolving models. Health care systems are complex adaptive systems that are resistant to change. It comes as no surprise then that the overall impact of pay for performance (P4P) systems on quality of care in various venues has, to date, been questionable.2,3 Under a P4P system, provider payments are determined, at least in part, by their performance on standardized measures of care quality. In theory, the idea is that providers will strive for high-quality care if better performance is rewarded with proportionately higher payments. Various barriers have been encountered in implementing P4P systems. It has been difficult finding accurate measures of performance, convincing providers to participate, structuring effective incentives, and changing provider behavior.4 Despite these barriers, as well as limited experience with P4P systems in NHs, the NH environment would seem to lend itself to potential P4P successes. Characteristics that are potentially aligned with P4P include care delivery in a single setting under controlled conditions, a relatively simple organizational structure, standardized data collection tools (e.g., the minimum data set) that provide abundant data on clinical quality, and state government positioned to lead quality