Clinical TopicsPatient SafetyWorkplace Management

PR, P4R, P4P, VBP. Connecting the dots with all of the “P’s”


Choices, choices, choices. It is so easy to be confused about which is the best product or service. That’s why I am a big fan of Consumer Reports. You see, writers evaluate and report publicly the performance of products or services based on assessment criteria. When looking to purchase a car, I consulted Consumer Reports to see how the cars performed and, in particular, the comparative safety performance of each vehicle and how the cars were rated.

In today’s healthcare environment, consumers want similar information to compare the performance of hospitals and healthcare providers to make informed decisions about where to go or whom to see.

The stated goal of Centers for Medicare and Medicaid Services (CMS), the largest payer of care for the Medicare population, is to “transform Medicare from a passive payer of claims to an active purchaser of care.” The goal has resulted in an alphabet soup of quality initiatives: Public Reporting (PR), Pay-for-Reporting, Pay-for-Performance, and Value-Based Purchasing.

CMS first reported hospital mortality rates of Medicare patients in 1984. By 2002, CMS launched several quality initiatives for nursing homes, home health and hospitals. Some hospitals initially volunteered to report on healthcare measures, available publicly on the CMS website ( The low participation response led CMS to institute Pay-for-Reporting, or P4R, whereby CMS pays hospitals an incentive to report quality-related data to improve participation in reporting the designated measures.

Next, CMS implemented Pay-for-Performance, or P4P. CMS’s current iteration of P4P is the Value-Based Purchasing, or VBP, program, which essentially says “Show us good performance and we’ll show you the money.” During this phase, there have been pilot studies or demonstration projects in which facilities and providers received an incentive based on performance. CMS has submitted a report to Congress identifying an implementation plan for VBP, which is similar to P4P in that both link payment to performance. Also on the federal horizon is the inverse of P4P, which is no pay for poor performance.

So how does this apply to nursing? The nursing profession has done extraordinary work related to quality. Many years ago, ANA’s House of Delegates recognized the need and ANA subsequently convened an expert panel that envisioned a leadership role for nursing quality. ANA’s support for the pilot studies evaluating linkages between nurse staffing and patient outcomes led to the creation of the National Database of Nursing Quality Indicators™ (NDNQI®).

NDNQI has been very successful nationally in leading the development, implementation, and reporting of nursing measures. Nursing measures have demonstrated that they make a difference in quality improvement and patient outcomes and are not limited to acute-care settings but span the continuum of care.

None of the CMS initiatives described include nursing measures despite substantial evidence of their value in improving the quality of patient care; how-ever, there is progress in that CMS is considering including them. Nursing measures are also not included in private payer initiatives.

As commonly said in the healthcare community, “Where goes Medicare—goes the private insurers.” Nurses must seize the opportunity to educate consumers and the larger healthcare community about the importance of adding this important perspective to these current quality improvement efforts. Write letters to newspaper editors or submit an entry in a community blog. Individual nurses can have an impact by advocating in their organizations and workplaces for the reporting and evaluation of nursing measures, and by collecting accurate data, thinking of research questions, making improvements at the bedside, and getting involved in their own states’ quality improvement organizations.

Finally, when a hospital or provider of care receives the performance-based incentive from CMS, it is in the employer’s best interest to assure that the incentive reward reaches the individuals responsible for improving outcomes—often the staff nurses of America, who deserve no less and should be rewarded the incentive for their role in the desired patient outcome.

Rebecca M. Patton, MSN, RN, CNOR
American Nurses Association

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