Robert Margolis, MD, has been the managing partner and CEO of HealthCare Partners since the formation of the company in 1992. Dr. Margolis was a founding partner and the managing partner of HealthCare Partners' predecessor, California Primary Physicians Medical Group. Under Dr. Margolis' stewardship, HealthCare Partners has become a highly respected and innovative physician-owned and operated medical group, IPA and MSO.
Dr. Margolis has been on the leading edge of the managed care industry for more than 20 years. He is a much sought-after spokesperson due to his vast experience in integrated delivery systems and physician practice management.
He is chairman of the Board of Trustees for California Hospital Medical Center, Los Angeles and serves on the boards of several prestigious health care organizations. These include the National Committee for Quality Assurance (NCQA) where Dr. Margolis is Chairman-elect and the California Association of Physician Groups (CAPG). He is a member of the Executive Management School Advisory Committee, School of Public Health, at University of California Los Angeles. He is a past member of the Catholic HealthCare West, Southern California Board of Directors and its Strategic Planning Committee. Dr. Margolis is past chairman of the American Medical Group Association and a two-time past chairman of the Unified Medical Group Association.
Dr. Margolis is board certified in internal medicine and medical oncology, and while practicing was an active member of the American College of Physicians and the American Society of Clinical Oncology. He is a graduate of Rutgers University and the Duke University Medical School and served a fellowship at the National Cancer Institute.

Question #1:

In your opinion, what are the most significant obstacles to achieving and rewarding provider quality?

In order to assess and reward quality delivery and outcomes in medical care delivery, many obstacles need to be overcome, incentives need alignment and physicians and their clinical teams need to understand the benefits and goals of the undertaking.
As an industry, we in healthcare, have done a poor job of defining quality care, differentiating it from service quality and communicating to and collaborating with our patients (consumers) on what is quality, why it matters and how, together, patients and physicians can improve the care currently being delivered. Without being at all exhaustive, the obstacles to improved quality lie in defining clear quality goals and expectations, and advocating and adopting best evidence of medicine guidelines to attain these goals. It is critical that both professionals and patients feel that these goals are relevant and important to achieve. And equally importantly, we need a system of compensation that aligns the rewards system in healthcare to actually pay more for good results and that doesn't reward rework, complications or poor results.

Question #2:

In your opinion, what are the most forward thinking initiatives or solutions that should be widely explored to achieve the systematic change necessary for successful pay-for-performance?

I am a firm believer that behaviors follow incentives. Currently the incentives are all mis-aligned. Consumers don't demand better quality and don't have information on which to make intelligent choices. Even when available, quality data is usually not as persuasive as service experience in influencing patient-choice. On the delivery side, payment incentives in most of the U.S. are mis-aligned. Fee for Service medicine encourages all the behaviors that have given us the system we have. Until we, in my opinion, move to a system where a substantial (25+ %) of compensation is tied to results, our current system is unlikely to change dramatically. It seems that the most practical and effective way to re-align the compensation in healthcare is not to scrap the FFS system entirely in favor of capitation (which I would support as a better starting system, as long as it was appropriately risk adjusted), but rather to "add on" a strong component of goal based quality measurement and reward - Pay for Performance.

Question #3:

Please expand on any initiatives with which you are currently involved that benefit your organization or the health care industry.

Within California, medical groups and IPA's over several years, and with lots of debate, have embraced the P4P program created through collaboration with employers, consumers, provider groups and plans. In this program the plans agreed on a standardized set of measurers across all major plans, a process for introducing sound and relevant new measurers and an overall program to bonus medical groups and IPA organizations on both threshold results, as well as year over year improvement. With these parameters in place and well communicated, supported by consumer and purchaser groups and covering, on a voluntary basis, essentially all the physician groups and IPA's in the state, momentum built and the program has created significant and measurable quality improvements in its first full year. New measures have been added after pilot year testing and the program is expanding to more organizations.

While still faced with challenges over funding and support from all plans, there is an expectation that has been created that will, in my opinion, continue to produce improving results year over year. The major weakness in this P4P program, as it is in most programs, is the measurements and public reporting are confined to HMO managed care membership. We desperately need comparison quality measurement across all insurance products to allow for informed decisions by consumers, employers and policy makers on where they receive the best value for the premiums that are paid.

Question #4:

Please provide highlights of your presentation at the Leadership Summit and any preliminary results or data that can be shared.

I look forward to presenting updates on the learnings from, and the future prospects of, the California Integrated Healthcare Association Pay for Performance project. At the World Congress meeting in August, we will be able to explore the processes that led to the program, the challenges during inception and how they were overcome, the current state of the program and the results to date.

There will be opportunity for a lively debate about the merits and pitfalls of P4P as a major driver of quality improvement.