Dr.Siegel is a Professor of Diagnostic Radiology and the Radiology Associate Vice Chairman for Informatics, Diagnostic Imaging, University of Maryland Medical Center;and the Director, Baltimore Veterans Affairs Medical Center, Baltimore, MD.He is also a member of the Editorial Board of this journal.

As I recall, getting a gold star or a smiley face in kindergarten was always really satisfying and a great motivator, even if it was just for paying attention and not interrupting the teacher as she read to the class. After kindergarten, they substituted grades when gold stars didn't seem do the trick anymore. We were told that grades were really important (after the 4th grade, everything you did was now on your "permanent" record) and that we would do fine as long as we worked hard, got things done on time, showed up on time, and participated in class. I can remember being chagrined in a college English class when I heard that our teacher graded our term papers by simply weighing them on a scale. This seemed both contrary to what we were taught and simultaneously an invitation to "game the system" by using heavier paper or a larger font size or substituting volume for quality and creativity.

As physicians and radiologists, we've grown accustomed to a system that provides reimbursement in a manner analogous to that English teacher-a system that uses a pay-for- volume rather than a pay-for-performance model. This system also seems to reward those who learn how to game the system and fails to recognize the quality of the studies that we obtain on our patients, of our diagnostic interpretations, or of the service that we provide to our patients and clinical colleagues.

The concept of pay for performance (P4P) seems to have a groundswell of support in the U.S. healthcare system, including a strong recommendation from the Institute of Medicine ¹ (Table 1). There are several reasons for this, including the apparent success of P4P in countries in Europe and Asia, inflationary pressures within healthcare (a 6.9% rise in total health expenditures in 2005, a 7.7% increase in employer health insurance premiums in 2006, and 16% of the gross domestic product spent on healthcare in the United States), the emergence of consumerism in healthcare, a renewed interest in healthcare quality, and the emergence of more sophisticated healthcare information systems. Major projects to introduce and study P4P in the United States have been initiated by The Leapfrog Group and the Robert Wood Johnson Foundation, including the Rewarding Results Program, which has increased the frequency of patient visits for primary care, accelerated the adoption of information technologies, and increased the use of annual screening mammography. Other noteworthy projects include the Bridges to Excellence Program as well as efforts by Partners HealthCare System, the Integrated Healthcare Association, and the Centers for Medicare and Medicaid Services (CMS).

The CMS started a P4P initiative on July 1, 2007, offering up to a 1.5% bonus for radiologists who wish to report on quality control measures related to stroke diagnosis using CT and MRI and follow-up evaluation of carotid stenosis in these patients using one of multiple modalities.

The American College of Radiology supports P4P as a "golden opportunity for radiologists to receive the full recognition and long-overdue value-added compensation for the superior services they provide." They have created a metrics committee to develop performance measures, hired full-time P4P staff, interacted with and provided input to governmental and political entities that affect P4P, and participated in national meetings such as the annual National P4P Summit.

Potential problems with pay for performance

Despite its billing as a "golden opportunity," P4P will inevitably present itself to radiologists as a double-edged sword. It will increase income for some providers in the short term and will undoubtedly improve performance metrics (such as patient satisfaction, waiting times, and report turnaround). It may increase the overall quality of interpretation by introducing a greater degree of peer review and by requiring additional training or subspecialization, although this has not yet been proven, and it may result in more effective utilization of imaging services and awareness of the expertise and experience of diagnostic radiologists. In the medium and long-term, however, it could be used to selectively justify reductions in payments for groups that do not meet specified criteria in a no-pay model or even in a penalty-for-underperformance model, which represents the flip side of the coin. Unrealistic performance goals could add stress to radiology practices that are already finding it difficult to cope and could be used for political purposes to undermine the practice of radiology in the future.

Recommendations

Radiology information systems (including scheduling software, PACS, and radiology reporting systems) are currently patient centric; they do not communicate with each other or facilitate the creation of quality-of-care reports, such as average patient scheduling times or patient waiting times in the department. These systems will need to be updated and will need to be able to generate automated reports about these and other metrics such as contrast extravasation and contrast reaction rates, repeated examination rates, patient identification error rates, radiation doses, radiologist peer review, patient satisfaction levels, and report turnaround times. Various insurance companies and other payors will define their own metrics, which will require the development of more flexible, integrated, and sophisticated information retrieval and reporting systems and the creation of standards for reporting these in a uniform manner.

Benchmarks should be created within the national and local imaging community and within an individual practice. From time to time, each practice should be evaluated against these benchmarks.

The culture of the radiologists and staff should become even more strongly oriented toward patient and clinician service, with continuous patient and clinician feedback.

Radiology residents should strongly consider obtaining additional credentials, such as specialty fellowship training. In a P4P system, these credentials will likely be used by payors to determine the level of compensation for services provided.

Conclusion

Pay for performance may well turn out to be just like the gold stars from kindergarten: satisfying and easy to get at first and a great motivator to genuinely improve quality and performance. Then, before you know it, they'll be substituting stars with grades and will start talking about your "permanent record." In any case, it's definitely time to start paying attention. Pay for performance is just around the corner and gold stars are going to be tough to come by, even for the best kids in the class.