Perspective:

This analysis by Epstein and colleagues provides some reassurances that P4P programs may not lead to avoidance of high-risk surgical patients due to concerns of financial penalties. P4P is well-known to American cardiologists. It is one of the major mechanisms by which payers and policy-makers are seeking to reform the fee-for-service payment system. P4P programs also will only grow in coming years through the large Medicare Value-Based Purchasing (VBP) program (built into the Affordable Care Act) and private insurance programs that closely mimic it. Although a rigorously performed analysis, there are some caveats to this study that deserve mention. First, it only deals with the Premier program—a program that has been criticized for ‘modest’ incentives that may not have influenced provider behavior as much as hoped. Yet, Premier remains the model for the larger Medicare VBP program, and thus, these results have implications for that program. Second, the analysis had to rely on claims data for risk-adjustment, which also means that appropriateness of CABG rates after AMI could not be ascertained (especially relative to medical therapy or percutaneous coronary intervention). Despite these limitations, this study is important and should comfort policy-makers hoping to use P4P programs to push our healthcare system even further toward the concept of increased ‘value.’