1. By Jillian Kelly, Tania Marmolejos, and Kristin Botzer
Performance Evaluations Related
To Patient Outcomes:
Con

2. What is Pay-for-Outcomes Based Care?
 Developed by managed care organizations to replace “Pay-for-Performance”
("PTPN’s pay-for outcomes program," 2013).
 Recognizes and rewards organizations getting patients better efficiently
("PTPN’s pay-for outcomes program," 2013).
 Paying hospitals and providers that meet particular quality measures and
clinical outcomes (Burns, 2011).
 Pay for outcomes has become popular with Medicare and Medicaid, huge payers
with a huge patient database that we deal with every day. (Health Policy
Beliefs, 2012)
 The Affordable Care Act in place by President Obama has promoted this.
(Health Policy Beliefs, 2012)

3. What is a Performance Review?
 An opportunity to discuss job performance.
(including positive or negative events that may have occurred altering
quality measures)
 A time to set professional goals.
 A chance to discuss your contribution to the department’s mission.
 An opportunity to discuss expectations and accomplishments you have
achieved.
(The University of Tennessee Knoxville, n.d.)

4. Performance Evaluations Tied to Patient
Outcomes
 “Tools intended to induce provider behavioral change to foster
performance improvement and add value” (Kurtzman et al., 2011,
para. 1).
 “Pay bonuses to providers for demonstrated improvements in the
quality of care” (Kurtzman et al., 2011, para. 1).
 “More than half of commercial health maintenance organizations
(HMOs) and state Medicaid programs operate pay-for-performance
programs” (Kurtzman et al., 2011, para. 1).
 “Medicare is also adjusting its reimbursement rates to reward quality
through various incentive programs”(Kurtzman et al., 2011, para. 1).
 Consider the comic to the right. How many of us have had
days like this? If we were all in it for the money, we would not
still be in the profession. Bonuses and incentives based on
patient outcomes is unrealistic. We can do everything in our
power to appease patients and save their lives, but many
times, it just isn’t enough. And at the end of the day, we still
deserve to be paid.

5. Factors Affecting Success
Size of incentive:
 Some programs with incentives of $2 per patient have had improved quality;
whereas programs with high incentives of up to $10,000 per practice have had
no improvement in quality (Werner et al., 2011). .
Public Reporting:
 Prior research has proposed that public reporting of information about
hospital’s quality of care is what improves that quality. So, since public
reporting and the CMS P4P project launched the same year, it is hard to tell
which one caused the improvement in quality (Werner et al., 2011).

6. Factors Affecting Success
Availability of Resources:
 Hospitals without the resources to invest in changes to improve quality will
not succeed in receiving incentives.
EXAMPLE
Staffing and technology are two areas that require maintenance and
investment. If hospitals reduce investments during tough financial times,
this program will worsen the hospital’s financial grading (Werner et al.,
2011).
Lack of consistency:
 Studies done thus far have shown that the effects of pay-for-performance
have been short lived and in the long run, performance scores were
equivocal. (Health Policy Beliefs, 2012)
 Other studies done have showed no difference in mortality rates between
those participating in a pay-for-performance initiative versus those not
participating. (Health Policy Beliefs, 2012)

7. Harmful Consequences
 P4P(Pay for Performance) uses a medicalization approach instead of the
recommended holistic approach. This causes excessive uses of unneeded
treatments.
EXAMPLES:
- Controlling illnesses such as hypertension and/or hyperlipidemia can
lead to unnecessary drug treatments and a greater risk for adverse effects on
patients.
- The increase of drug treatment in order to reach targeted patient
outcomes for incentive purposes, can lead to an increased in mortality rates.
****Respect for the person rather than the outcome, can easily
become vanished in the systems that pay for performance
related to patient outcomes.
(Siriwardena, 2014).
This leads us to ethical concerns related to Pay-for-Performance…..

8. Ethical Concerns
If patients are unaware that providers are incentivized to treat
certain illnesses, recommend certain treatments, or perform
certain tasks, this can weaken the TRUST and affect AUTONOMY.
(Siriwardena, 2014).
 Think about this: There is such a thing as over-treating a patient. When
healthcare professionals have monetary incentives to promote certain outcomes
and prevent mortality, they may treat patients aggressively. This could be
detrimental. Over using medicine and technology can have negative effects and
outcomes. It could also be dangerous because are patient wishes and desires being
taken into consideration every single time? Are we sure this is what our patients
want? Pay-for-performance could decrease healthcare professionals awareness of
patients emotional and psychological health. Remember we are in this field to
promote health and well-being but sometimes it isn’t about preventing mortality
but promoting patient DIGNITY.

9. Importance of this Issue on Nursing
According to the Robert Wood Johnson Foundation (2009),
 “Nurse leaders and researchers are interested in figuring out how pay for
performance can incentivize nurses to improve patient care and control costs
in all settings, to date pay-for-performance programs have typically focused
on hospitals and physician practices” (p.2).
 “Although hospital care is provided primarily by nurses, current
reimbursement formulas ignore the specific, unique services nurses provide
and merely consider nursing as part of room and board charges” (p. 2).
 “Experts are concerned about the pressures that pay-for-performance
initiatives will place on institutions already struggling with staffing shortages,
especially those that serve vulnerable populations” (p.3).

10. Issues with Evaluating Nurses by Patient
Outcomes
 Pay-for-performance programs result in financial penalties on nurses
who do not meet the specific goal(s).
Is this fair?! We have all had difficult patients that are impossible to
please or patients who still end up passing. How would you feel if this
resulted in a pay grade decrease?
 Pay-for-performance (P4P) is a scheme that has a goal to perform more
efficiently than other organizations, INSTEAD OF to improve overall
quality.
 Will providers avoid disadvantaged populations so that their
performance scores do not decrease?
A study done by Alyna Chien at Weill Cornell Medical College observed
that providers caring for patients residing in the lower-income
areas in California, received lower performance scores than others.
*An analysis of Medicare data showed that hospitals caring for low-income
patients will be penalized greatly due to excessive increased ratios of
preventable hospital readmissions.
(Health Policy Brief, 2012)

11. Issues with Evaluating Nurses by Patient
Outcomes (continued)
 Creativity is lost and attention is narrowed in those who receive incentives for
performance and positive patient outcomes.
 Healthcare providers who receive financial incentives are distracted from
important duties, by constantly thinking of the reward they may receive or
may not receive from their performance.
 Many studies in the USA and India illustrated that high incentives lead to
poorer performance, compared to low and/or reasonable financial incentives.
(Siriwardena, 2014).
 Pay-for-performance is ultimately a negative motivator for healthcare
professionals.
 It could draw forth the wrong individuals to the field chasing the money and
incentives. The best healthcare workers are those who have the patient at
heart and not the dollar. Those in it for the money do not last and do not
provide the best patient care, instead they are task oriented and lack the
bedside abilities.

12. Issues with Evaluating Nurses by Patient
Outcomes (continued)
 Evidence from behavioral economics propose that monetary incentives are
likely to result in WORSE performance.
HOW?
“Choking under pressure”- a well known Yerkes-Dodson law that
states, when performance increases with anxiety, a threshold is reached to a
point that destroys performance levels. What does this mean?
Receiving monetary bonuses related to patient outcomes can
cause healthcare providers to overthink tasks and problems, which will
ultimately lead to worse performance and bad patient outcomes.
(Siriwardena, 2014).

13. Questions Without Answers
 Pay-for-outcomes programs will most likely be expanding nationwide in the
future.
HOWEVER…….
 How can performance improvements last over time?
 How large does the payment have to be to produce wanted changes?
 How often should rewards be given out?
 What consequences will this have on populations who are financially weak
and/or that contain greater minority groups?
(Health Policy Brief, 2012)
 Should payments go to the individual causing positive patient outcomes or
to the entire organization? (Siriwardena, 2014).
 Evaluations will need to be long term, to allow for identification of
unintended consequences (Health Policy Beliefs, 2012)

14. Addressing the Opposing Side
 Claim: Increases the quality and safety within healthcare institutions.
Implication : “Nurses may need to spend even more time away from patients
documenting care. Some studies show that nurses in acute care already
spend 30 percent or more of their work time on documentation” (Robert
Wood Johnson Foundation, 2009, p. 8).
More time spent on documentation…..is that really what nurses need?
 Claim: Will lead to higher quality nursing performance.
Implications: The expectation is that there will be an initial increase in
disciplinary action (Osborne, 2014). Nurses are concerned about absorbing
blame for occurrences such as hospital-acquired infections (Kurtzman et al.,
2011).
Will this cause animosity and lateral violence? Will nurses be afraid to
report errors?
 Claim: It is a cost saving measure.
Implication: Viewed as increasing the demands on nurses with little effect on
reducing turnover or salaries (Kurtzman et al., 2011).

15. Addressing the Opposing Side
(continued)
 Claim: These programs show results.
Implication: A study of the Premier Hospital Quality Incentive Demonstration
project showed that hospitals improved their quality of care rates after
the implementation of this program. However, this ONLY lasted 5 years.
Is it worth the time and effort for a short term goal? Will nurses be
penalized financially for not meeting outcome expectations?
 Claim: Paying for quality not quantity is better.
Implication: Defining “quality” of care is hard, almost impossible. Quality
of care for one patient in one situation, is totally different to another
patient in another situation (Carroll, 2014).
How are insurance companies going to pay healthcare providers based on
quality if it is different in every situation? What is their definition of
quality? Does every payer have their own definition?

16. Addressing the Opposing Side
(continued)
 Claim: Refusing to pay for hospitalizations that have hospital acquired
pneumonia, UTI’s, etc. will reduce the rate of such infections.
Implications: In 2008, Medicare thought that this would improve
performances in hospitals and improved care but that did not happen. This
policy has little to no measurable effect. (Carroll, 2014)
Measurements used in determining pay did not account for things out of the
providers control such as: environment, income, housing, and education.
This means that hospitals in cities or low economic settings, that care for
the poor, are penalized because the measurements do not account for items
out the hospital and providers hands. (Carroll, 2014)

17. The End

18. References
 About a Nurse [Cartoon]. (n.d.). Retrieved from
https://www.pinterest.com/pin/10062799140673001/
 Burns, J. (2011, September). At long last… pay for outcomes starts to replace
pay for performance. Managed Care. Retrieved from
http://www.managedcaremag.com/
 Carroll, A. (2014). The Problem With ‘Pay for Performance’ in Medicine. The
New York Times. Retrieved from
http://www.nytimes.com/2014/07/29/upshot/the-problem-with-pay-for-
performance-in-medicine.html?_r=0&abt=0002&abg=1
 Getty Images. (2014). Stop the defensiveness; come up with a plan to address
your shortcomings. [Photograph]. Retrieved from
http://www.usatoday.com/story/money/
 Green Career Central. (2014) Feeling Boxed In By Your Career? There's a Way
Out. [Photograph]. Retrieved from http://www.greencareercentral.co
 Health Policy Brief: Pay-for-Performance. (2012). Health Affairs. Retrieved
from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78.

19. References
 Kruse, K. (2012). Performance appraisals: 4 reasons why they must be
abolished. Retrieved from http://www.kevinkruse.com/
 Kurtzman, E. T., O’Leary, D., Sheingold, B. H., Devers, K. J., Dawson, E. M., &
Johnson, J. E. (2011). Performance-based payment incentives increase
burden and blame for hospital nurses. Health Affairs, 30(2), 211-218.
http://dx.doi.org/10.1377/hlthaff.2010.0573
 Manary, M. P., Boulding, W., Staelin, R., & Glickman, S. W. (2013). The patient
experience and health outcomes. New England Journal of Medicine, 368, 201-
203. http://dx.doi.org/10.1056/NEJMp1211775
 Mt. Vernon Nursing & Rehab Center. (2015). Long-term care [Photograph].
Retrieved from http://www.mvnrc.net/services/
 National payers adopt PTPN’s pay-for outcomes program for physical therapy
and occupational therapy services. (2013). Managed Care Outlook, 26(4), 1-5.
Retrieved from http://www.ebscohost.com/
 Nurses, be stress free in 10 seconds. (Photograph). Retrieved from
http://www.nursetogether.com/

20. References
 Osborne, K. (2014). Employers welcome guidance on performance-related pay
systems. Nursing Standard, 28(42), 14-15. Retrieved from
http://www.nursing-standard-journal.co.uk/
 Robert Wood Johnson Foundation (Ed.). (2009). Perspectives on pay for
performance in nursing: Key considerations in shaping payment systems to
drive better patient care outcomes. Charting Nursing’s Future. Retrieved
from http://www.rwjf.org/en.html
 Siriwardena, A. N. (2014). The ethics of pay-for-performance. Quality In
Primary Care, 22(2), 53-55.
 The University of Tennessee Knoxville. (n.d.). Performance Evaluation.
Retrieved from http://hr.utk.edu/performance-evaluation/
 Werner, R., Kolstad, J., Stuart, E., & Polsky, D. (2011). The effect of pay-for-
performance in hospitals: Lessons for quality improvement. Health Affairs,
30(4), 690-698. Retrieved from
http://content.healthaffairs.org.pacollege.idm.oclc.org/content/30/4/690.f
ull.

21. Color Key
 Jillian Kelly – Blue
 Tania Marmolejos – Black/Red
 Kristin Botzer - Green