Overview

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This section is devoted to providing a ten-thousand-foot view of pay-for-performance (P4P), which has many definitions. Features common to most definitions include an insurer or health system awarding a periodic bonus to clinicians or practices that reach particular quality goals. There are three types of quality markers: structure (EMR), process (checking HbA1c every 3 months in type 2 diabetics), or outcome (HbA1c < 8.0%). Programs are currently free to choose the measures and rewards they see fit. The reward, or incentive, is typically a cash bonus ranging from program to program between 1% and 25%. Most P4P rewards are over and above traditional fee for service or capitated payments. However, some P4P programs are funded by withholding a percentage of the traditional payments. Apart from P4P proper, insurers and health systems are using incentives such as physician report cards and tiering to exert additional financial and social pressure for clinicians to achieve quality goals.  Historically P4P was conceived of as a quality improvement tool. More recently it has been described as a strategy for promotion of cost-effectiveness or value-based care. From its inception P4P has been surrounded by controversy, which is discussed in detail throughout this website, specifically in Controversial Issues.

 

The most recent research indicates P4P has overall shown positive clinical effects for most diseases, but implementation may bring about negative unintended consequences, particularly related to health equity (420). It is also true that P4P evidence is mixed and difficult to analyze. Allen urges that new schemes must be designed from the beginning to better allow evaluation, including control and treatment groups coupled with before and after data (383). Despite overall encouraging clinical effects seen, a review of the world's largest primary care P4P program, the United Kingdom’s (UK) Quality and Outcomes Framework (QOF), showed no significant association with improved population mortality for any assessed disease area, both those targeted and not targeted by the QOF (425). Additionally, a recurring problem with P4P and value-based care is the lack of agreement on what value in healthcare is, how to produce greater value, and how to identify when value has been achieved. It has become increasingly popular to caution against “measurement for measurement’s sake” due to the burden placed on providers and the potential shift in attention away from non-incentivized areas which may impact patient outcomes more significantly. Antos illustrates how it is becoming an increasingly important challenge to effectively “mesh the differing perspectives of payers, providers, and consumers on what constitutes value in healthcare” (414).

 

As the acceptance of P4P expands, so does the influence of its programs, and the amount of patients it reaches. The Center for Medicare and Medicaid services (CMS) has contributed largely to the growth of P4P, especially with the implementation of the Medicare and CHIP Reauthorization Act (MACRA) looming. A section on this website is devoted to the CMS National Program under "Programs." Other quality improvement organizations such as Bridges to Excellence, Leapfrog (67), AHRQ, and IHA, continue to contribute to the expansion of P4P.

 

Both journal articles (22581117118142153163) and newspaper articles (92128135290302) reflect a general entrenchment of P4P within American health care. Many articles provide quality overviews of payment models in general (345, 348) as well as the principles of P4P (25152153198266303). Specifically, Chaix-Couturier (267) demonstrates that in all physician payment systems there are financial incentives which can cause perverse outcomes. Conrad (292) provides a general overview of the controversies surrounding P4P. Perhaps the most comprehensive overview of all the early P4P literature through 2009 was written by Greene and Nash (326). 

 

The rapid expansion of P4P in the United States has produced a wide variety of programs. This heterogeneity has led many to question, "What does an effective P4P system look like?" Researchers (135178192203204308) continue to study this question and provide recommendations. There is a great deal of research and opinion on what determines the success of a P4P program included in our section entitiled Program Design and Implementation. Several sections of this website are devoted to answering various aspects of this general question such as, "Should P4P programs risk adjust by patient population?", "Should programs pay for achieving clinical outcomes or adhering to guidelines?", and "Should programs allow for exception reporting when a patient's medical condition conflicts with a suggested measure?"

 

Despite much controversy and public criticism, physicians are increasingly accepting P4P (180190). This topic is also examined in the Provider Viewpoint section under Data and Outcomes. Furthermore, the concept of performance-based reimbursement has been incorporated into health care system designs such as accountable care organizations, bundled paymentsmedical homes, P4P for patients, and value-based purchasing. These topics are discussed further in their own sections within "Alternative Performance-Based Programs."

 

 

Website Authors' Opinion

There are many good overviews of P4P in the literature. The biggest challenge to date has not been defining it, but rather putting forward a program that physicians, payers, and patients are all satisfied with. Until then, the world of P4P has a lot of potential as it can tie many aspects of care to incentives that can either pay for the care, or provide bonuses to provide that care well. 

 

 

Overview Literature

Key Articles: 326, 345, 348, 383, 420, 425

 

(2) Henley, E. Pay-for-performance: What can you expect? The Journal of Family Practice. 2005: 54(7) 609-612.

PMID: 16009089

Summary:

  • Provides overview of P4P, and how prominent groups like CMS and Bridges to Excellence are using it.
  • Mentions difficulties in implementation.

Significance to Literature:

Overview of P4P through 2005.

 

 

(9) Seuiguer E. In Health Care, Do We Get What We Pay For? Focus at Harvard Medical School. June, 2004.

Summary:

  • Summarizes P4P through 2004.
  • Lists criteria of P4P including: clinical, patient experience, and investment in information technology.
  • Questions if P4P will be enough to improve quality.

Significance to Literature:

P4P has similar issues today as it did in 2004.

 

 

(21) Casey BR. What is Pay for Performance? Kentucky Medical Association. 2006: 104(5): 177-178.

PMID: 16734040

Summary:

  • Brief letter from Kentucky Medical Association president-elect summarizes P4P, why it exists, and who is using it in 2006.

Significance to Literature:

An overview of P4P in 2006.

 

 

(25) Wachter RM. Expected and Unanticipated Consequences of the Quality and Information Technology Revolution. JAMA commentary. 2006: 295(23) 2780-2783.

PMID: 16788133

Summary:

  • Article warns that new technologies often bring unwanted consequences.
  • Author believes the same will happen with quality measures playing a large factor in healthcare.
  • The only way to find out some consequences is to test out the innovation.

Significance to Literature:

Advocates innovation, and warns of consequences.

 

 

(28) Endsley S, Baker G, Kershner BA, Curtin K. What Family Physicians Need to Know About Pay for Performance. Family Practice Management. July/August 2006.

PMID: 16909831  Link: http://www.aafp.org/fpm/20060700/69what.html

Summary:

  • Outlines growth of P4P programs, and types of incentives.
  • “CMS” will have a big influence.”
  • Lists 5 questions family physicians need to think about.

Significance to Literature:

Outlines the state of P4P in 2006.

 

 

(67) Dolan PL. Leapfrog updates P4P Web site. January 14,2008.

Link: http://www.leapgfroggroup.org/compendium2

Summary:

  • List of P4P programs—Follow http://www.leapfroggroup.org/compendium2 to view a list of numerous P4P incentive programs currently in place.
    • Database has 49 programs as of January, 2008.
  • Leapfrog is a consortium of large employers who want to improve health care delivery and lower costs.

Significance to Literature:

January 2008 news article about Leapfrog.

 

 

(81) Rowe, JW. Pay-for-Performance and Accountability: Related Themes in Improving Health Care. Annals of Internal Medicine. 2006: 145(9) 695-699.

PMID: 17088584

Summary:

  • Reviews the critical design features of current P4P efforts.
  • Comments on the implications of emerging P4P programs.
  • Looks at the United Kingdom P4P model.
  • Details implications of who get the incentives for what measures.

Significance to Literature:

Assesses the implications of emerging P4P in the US in 2006.

 

 

(105) Tanne JH. US gets mediocre results despite high spending on health care. British Medical Journal. 2006: 333 672.

Link: http://www.bmj.com/cgi/content/full/333/7570/672-b

Summary:

  • The US spends twice as much on healthcare as a percentage of GDP compared with other industrialized nations.
  • Quality of care is highly variable despite this.

Significance to Literature:

Results from the Commonwealth Fund’s Commission on High Performance Health Systems from September 20th, 2006.

 

 

(117) Apodaca MD, Medicare and the Physicians’ Pay-for-Performance: Will it Create More Problems than is Can Solve? Journal of Health Care Compliance. 2007: 37-38, 76-77.

Link: http://www.brownmccarroll.com/articles_detail.asp?ArticleID=232

Summary:

  • Outlines Medicare’s P4P program, its growth, and acceptance within the current healthcare model.
  • Lists attributes and objections to P4P.
  • Significance to Literature:
  • Short review of benefits and burdens of P4P in 2007.

 

 

(118) Young GJ, Conrad DA. Practical Issues in the Design and Implementation of Pay-for-Quality Programs. Journal of Healthcare Management. 2007: 52(1) 10-18.

PMID: 17288114

Summary:

  • Gives an overview of the theory of P4P.
  • Lists six design and implementation factors that need consideration, including:
    • Type of condition to pay for
    • Process vs. outcome
    • National vs. local standards
    • Who gets paid
    • How much to pay
    • How to measure quality
  • Also discusses payout formula options.

Significance to Literature:

Offers an analysis of designing and implementing P4Q(quality) programs.

 

 

(133) Kronenfeld JJ. Access, Quality, and Satisfaction: Three Critical Concepts in Health Services and Health Care Delivery. Research in the Sociology of Health Care. 2007: 24 3-14.

Link: http://www.emeraldinsight.com/doi/abs/10.1016/S0275-4959(06)24001-8

Summary:

  • Presents facts about current trends in insurance rates, and underinsured rates.
  • Defines patient satisfaction, and how it is usually measured.
  • Defines Quality of Care and what it contains.

Significance to Literature:

Offers definitions to P4P key concepts including quality, cost, access, and patient satisfaction.

 

 

(135) Satin DJ. Maximum-Strength Health Care May Cause Dangerous Side Effects. Minneapolis Observer. 2004.

Link: http://www.ahc.umn.edu/img/assets/23396/Maximum-Strength_Health_Care_Dav...

Summary:

  • Author describes the “American paradox” of spending more than all developed nations, but getting worse outcomes than most.
  • Reports on new Minnesota P4P model aimed at controlling costs and improving quality.
  • Describes how an effective P4P program might work, and suggests one P4P side-effect—“sick patients with little resources look like bad investments.”

Significance to Literature:

Describes Minnesota P4P proposal in 2004, and suggests area of concern.

 

 

(142) Spinelli RJ, Fromknecht JM. Pay for Performance: Improving Quality Care. The Health Care Manager. 2007: 26(2) 128-137.

PMID: 17464225

Summary:

  • Overview and summary of P4P through 2007.
  • Outlines and compares key players in P4P like JCAHO and AMA.
  • Describes how physicians, patients, insurers, and payers are potentially affected by P4P.

Significance to Literature:

Overview of P4P as it relates to various players in the health care system in 2007.

 

 

(152) Wells DA, Ross JS, Detsky AS. What is Different About the Market for Health Care? JAMA commentary. 2007: 298(23) 2785-2787.

PMID: 18165673

Summary:

  • Commentary outlines economics in health care, as well as three classic attempts to change market distortions in health care.
  • P4P aims at the asymmetry of information between patients and clinicians by offering reimbursement to clinicians and hospitals for appropriate health care services.

Significance to Literature:

P4P is another tool to limit the economic distortions in the health care market.

 

 

(153) Ralston Jr, JF. Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Annals of Internal Medicine Position Paper. 2008: 148(1) 55-75.

PMID: 18056654

Summary:

  • First, article outlines the current structure of the United States health care system.
  • Second, article uses the Commonwealth Fund criteria to compare the United States to other countries health care systems.
  • Lastly, the paper provides recommendations to create a better functioning health care system.
  • P4P is Lesson 10, recommendation 5, page 70
  • Incentives should be used to stimulate efficient care.

Significance to Literature:

“Achieving a well-functioning health care system that encourages quality improvement may require P4P programs.”

 

 

(163) Mannion R, Davies HT. Incentives in health systems: developing theory, investigating practice. Journal of Health Organization and Management, Guest editorial. 2008: 22(1).

PMID: 18488515 

Summary:

  • Provides a definition and an overview of P4P.
  • Highlights recent findings/results in other countries.
  • “Need to move beyond case accounts of on-the-surface-successful implementation of P4P schemes to more theoretically driven and analytic evaluations of such schemes in all their diversity.”

Significance to Literature:

Overview of P4P case results in many countries.

 

 

(178) Hazelwood A, Cook ED. Improving Quality of Health Care Through Pay-for-Performance Programs. The Health Care Manager. 2008: 27(2) 104-112.

PMID: 18475111

Summary:

  • Federal programs are emerging to improve quality by increasing transparency and offering P4P programs.
  • The key element in P4P is designing measures that will cause quality improvement.
  • Article expands on cases from federal programs, and private sector programs.

Significance to Literature:

It is imperative to monitor successes and failures of various models and consider the possibilities of implementing P4P.

 

 

(180) Guglielmo WJ. This Doctor made P4P work—you can too. Medical Economics. July 18, 2008.

Summary:

  • A growing number of physicians are accepting P4P, and using it to help guide care for their patients.
  • Outlines considerations clinics should use when deciding to implement P4P.
  • Outlines some of the advantages of successful participation in P4P.

Significance to Literature:

P4P is helping some small and large clinics perform better quality care.

 

 

(190) Mehrotra A, et al. The Response of Physician Groups to P4P Incentives. The American Journal of Managed Care. 2007: 13(5) 249-255.

PMID: 17488190

Summary:

  • Authors interviewed 79 physician group leaders in Massachusetts regarding their physician group use of incentives and quality initiatives.
  • Overall, 77% of the leaders expressed support for P4P following HEDIS measures, and 79% said it would result in quality improvement.
  • The use of P4P incentives was highly associated with quality improvement initiatives.

Significance to Literature:

Although the magnitude of incentives was relatively low, physician groups support P4P, while most use P4P for quality improvement initiatives.

 

 

(192) Frolich A, Talavera JA, Broadhead P, Dudley RA. A behavioral model of clinician responses to incentives to improve quality. Health Policy. 2007: 80 179-193.

PMID: 16624440

Summary:

  • The rationale for P4P and public reporting comes from experience in other industries and from incentive theories, however, now there are no conceptual models that pull theories from other disciplines and apply them to health care.
  • Report provides a brief conceptual model of P4P in health care.
  • Article reviews eight randomized control trials of incentive use, and highlights the weaknesses of these trials.

Significance to Literature:

Researchers must assess the complex behaviors and complex circumstances in future P4P research.

 

 

(198) Epstein AM, Lee TH, Hamel MB. Paying Physicians for High-Quality Care. NEJM. 2004: 350(4) 406-410.

PMID: 14736934

Summary:

  • Overviews some core concepts of P4P, including using P4P to stimulate immediate and long-term performance improvements.
  • Discusses prototypical P4P systems including:
    • Bridges to Excellence
    • The Integrated Healthcare Association’s Physician Payment Program
    • Anthem Blue Cross and Blue Shield
  • States challenges ahead for purchasers and physicians
  • Coordination of programs
  • Right mix of criteria
  • Threats to professionalism
  • Continued investment in measuring systems and tracking quality in an affordable way remains important.

Significance to Literature:

Identifies key issues about P4P in January, 2004.

 

 

(203) Young GJ, et al. Conceptual Issues in the Design and Implementation of Pay-for-Quality Programs. American Journal of Medical Quality. 2005: 20 144-150.

PMID: 15951520

Summary:

  • Article outlines 5 dimensions of P4P that must be taken into consideration in design and implementation.
  • Providers must be made aware of targets and understand programs
  • Size and structure of financial incentives
  • Quality targets must be studied, and chosen on relevance
  • Must recognize interdependencies of treatments among physicians
  • Scoring systems must take into account provider-level differences.
  • Authors also provide recommendations for further efforts to P4P.

Significance to Literature:

The diversity of P4P programs will provide natural experiments to analyze the best ways to provide financial incentives, and will provide a challenge to standardize P4P measures if necessary.

 

 

(204) Safavi K. Patient-Centered Pay for Performance. Are We Missing the Target? Journal of Healthcare Management. 2006: 51(4) 215-218.

PMID: 16916114

Summary:

  • In multiple surveys assessing patients desire in healthcare, in general, patients want good communication skills, compassion, and competence in their physician.
  • Current metrics of P4P are based mainly on technical aspects, and are not what the patient thinks is the primary driver of a good hospital experience.

Significance to Literature:

In the future of P4P, more attention will be paid to the nontechnical aspects of care.

 

 

(266) Shortell SM, Casalino LP. Health Care Reform Requires Accountable Care Systems. JAMA. 2008: 300(1) 95-97.

PMID: 18594045 

Summary:

  • Authors suggest implementing accountable care systems (ACS) for improving quality and controlling costs for patients.
  • As science and technology advance in the medical field, a co-evolution of incentives and the ability to respond to the incentives is necessary. This can be done through:
    • Medical homes
    • Rewards for improving quality
    • Bundled payments
    • Tiered incentives

Significance to Literature:

ACS is an overarching concept that integrates P4P for 21st century medicine.

 

 

(267) Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on the medical practice: results from a systematic review of the literature and methodological issues. International Journal for Quality in Health Care. 2000: 12(2) 133-142.

PMID: 10830670

Summary:

  • Identifies existing financial incentives and their results on costs, process or outcomes of care.
  • Multiple confounding factors cause different results from similar incentives.
  • Analyzes 8 randomized control trials of financial incentives.
  • Results were often preliminary or shortly after follow-up, thus limiting analysis of long-term effects.

Significance to Literature:

How physicians are paid does influence their practice patterns.

 

 

(290)  Williams CH, Christianson JB. Paying for quality: Understanding and assessing physician pay-for-performance initiatives. The Synthesis Project, Policy Brief No. 13. The Robert Wood Johnson Foundation. December, 2007.

Link: http://www.rwjf.org/files/research/no13synthesisbrief.pdf

Summary:

  • Offers highlights of issues that surround P4P, as well as policy implications P4P may have.
  • Summarizes key findings in the literature.

Significance to Literature:

Summary of P4P policy through 2007.

 

 

(292) Conrad DA, Perry L. Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It? The Annual Review of Public Health. 2009: 30 357-371.

PMID: 19296779 

Summary:

  • Review of P4P which incorporates microeconomic theory, behavioral economics, the theory of principal-agent behavior, cognitive psychology, and organizational theory.
  • Particularly discusses:
    • Use of rewards versus penalties
    • Nature of incented entity and focal quality behavior
    • Whether the incentive is general or selective
    • Extrinsic versus intrinsic motivation
    • Use of relative versus absolute performance measures
    • Size of the incentive
    • Certainty of the incentive
    • Frequency and duration of the incentive
  • Argues that group level incentives, continuous absolute performance incentives, and practice organizations able to maintain an EMR, are best suited P4P strategies.
  • Payments must also be timely in order to be effective.

Significance to Literature:

Overview of controversies of P4P in the literature in early 2009.

 

 

(302) Pay-for-Performance Special Section. AAFP. October, 2005.

Summary:

  • Series of 6 articles in a special section of the regular periodical.
  • Topics include:
    • P4P is first used for quality improvement, then as a positive financial recognition.
    • A Question and Answer section from Bruce Bagley of the AAFP.
    • P4P as a means to reduce error, and improve care.
    • It is a necessity to get physician input when designing programs.
    • The commercial media is beginning to play a larger role in evaluating P4P programs.
    • Key P4P stakeholders.

Significance to Literature:

Provides an overview of the key ideas of P4P in 2005.

 

 

(303) Heading for the emergency room. The Economist. June 27th, 2009.

Link: http://www.economist.com/world/unitedstates/displaystory.cfm?story_id=13...

Summary:

  • Quality of care provided does not correlate with the amount of money spent on care.
  • The real problem with the US healthcare system is the incentives used by payers to pay providers for their service.
  • A second big factor is the lack of competition amongst operators.
  • America is looking into P4P programs to help increase quality of care provided.
  • P4Pers should look at the Swedish incentives for hospitals to cut queues.

Significance to Literature:

P4P is becoming a mainstream tool to improve quality, its benefits in the US are unknown.

 

 

(308) Outcomes-Based Compensation: Pay-for-Performance Design Principles. American Healthways. 2004.

Link: http://www.healthleadersmedia.com/content/145150/topic/WS_HLM2_HOM/OUTCO... Then click on download the Whitepaper 

Summary:

  • 250 Physicians and medical managers consensus statement on outcome-based compensation could be developed to align health care toward evidence-based medicine.
  • Principles provided are meant as guidelines for organizations developing P4P programs.

Significance to Literature:

Influential document providing guidelines P4P must undertake to be successful in realigning physician compensation to increase the quality of healthcare.

 

 

Key Article


(326) Greene SE, Nash DB. Pay for Performance: An Overview of the Literature. American Journal of Medical Quality. 2009: 24(2) 140-163.

PMID: 18984907

Summary:

  • Extensive overview of all literature regarding P4P
  • In depth summaries of key financial incentive trials throughout the world.
  • Reviews physician perception of P4P.
  • Touches on cost analysis of P4P, support for P4P, and arguments against P4P.

Significance to Literature:

Extensive and in-depth article covering most current literature available regarding P4P. 

 

 

Key Article

(345) Khullar D et al. How 10 Leading Health Systems Pay Their Doctors. Healthcare. 2015 Jun;3(2):60-2. doi: 10.1016/j.hjdsi.2014.11.004. Epub 2014 Dec 16.

PMID: 26179724

Summary:

  • Interviews with senior executives at ten leading health systems including: Kaiser, Mayo, Intermountain, Geisinger, Cleveland Clinic.
  • Analysis of healthcare organizations utilization of performance-based compensation
  • Performance-based pay more prevalent in primary care than in subspecialties
  • Most have less than 10% of pay tied to performance

Significance to Literature:

Models with many metrics and low at-risk compensation for each metric are often ineffective at reaching goals

 

 

Key Article

(348) Martin W. A Look at Physician Compensation Models. Physician Leadership Journal. 2015 Jul-Aug;2(4):64-7.

PMID: 26285399

Summary:

  • Summarizes incentive structures and effect on quality of patient care for ten models of physician compensation
  • Compensation models included are fee-for-service, fee-for-value, pay-for-performance, salary, capitation, bundled payment, accountable care organization, concierge, direct pay contracting, and volunteering.

Significance to Literature:

An overview of how physician payment structure plays a vital role in the overuse, underuse, and misuse of healthcare resources


 

(366) Burstin H, Leatherman S, Goldmann D. The evolution of healthcare quality measurement in the United States. J Intern Med. 2016 Feb;279(2):154-9. doi: 10.1111/joim.12471.

PMID: 26785953

Summary:

  • Despite significant investment in healthcare quality and improvement, progress has been limited.
  • Authors indicate possible reasons for limited progress such as:
    • Lack of alignment in the use of measures and improvement strategies
    • Fragmentation of US healthcare system
    • Lack of national electronic systems for measurement and reporting
    • US needs to focus on identifying and utilizing measures that have the greatest effect on quality

Significance to Literature:

Overview of US quality measurement. Recommendations include streamlining and alignment of measures.

 

 

(371) Sipek S. Command Performance. Workforce. 2015 Dec.

Link: http://www.workforce.com/articles/21717-command-performance

Summary:

  • P4P success is dependent on whether or not financial incentives will influence physician behavior
  • Paying for quality seems obvious but can be challenging when defining quality is difficult
  • Lack of proper risk adjustment will likely result in “incorrect inferences about quality”
  • Employers have started monitoring performance of nearby hospitals and are exploring altering health plans to incentivize employees to utilize those with the highest quality ratings

Significance to Literature:

Magazine commentary summarizing how “As an economic theory, pay for performance makes sense” but “like diagnosing a patient, it’s not that simple.”

 

 

(372) Top 10 challenges facing physicians in 2016. Medical Economics. 2015 Dec 25.

Link: http://medicaleconomics.modernmedicine.com/medical-economics/news/top-10...

Summary:

  • Medical Economics presents their annual list of top challenges physicians will face in 2016
  • This year’s list includes: payment model changes shifting risk to physicians, ACA’s continued influx of new patients, chronic care management set up, payer consolidation, balancing independence and employment, maintenance of certification changes, meaningful use, remote medicine challenges, team-based care risks and rewards, and data vulnerability

Significance to Literature:

Overview of what challenges physicians can expect to face in 2016

 

 

(376) Laff M. Give Pay-for-Performance Chance to Succeed, Panelists Urge. American Academy of Family Physicians. 2014 Oct 16.

Link: http://www.aafp.org/news/practice-professional-issues/20141016p4p.html

Summary:

  • A panel of medical experts at an Alliance for Health Reform briefing advocated for greater efforts to be made on P4P models before labeling them failures
  • Panelists proposed exploration of alternative incentive forms, such as smaller, more frequent financial incentives or nonfinancial rewards
  • The question of how to effectively assess performance for hospital physicians, tasks not associated with a CPT code, and end-of-life care remains unanswered

Significance to Literature:

Pay-for-performance cannot be accurately evaluated simply as whether it works or not, but rather the medical community should continue to ask “how do we get pay-for-performance to work?”

 

Key Article

(383) Allen T, Mason T, Whittaker W. Impacts of pay for performance on the quality of primary care. Risk Manag Healthc Policy. 2014 Jul 2;7:113-20. doi: 10.2147/RMHP.S46423. eCollection 2014.

PMID: 25061341

Summary:

  • General overview of P4P theory and applications and their impact on the quality of primary care in the UK
  • Adoption of P4P is increasing worldwide despite ambiguous evidence for its efficacy and continued difficulty with the evaluation of programs
  • The authors outline a list of potential unintended consequences including: measure fixation, short-termism, manipulation of measures, gaming, etc.
  • Discussion of the United Kingdom’s ten-year-old Quality and Outcomes Framework (QOF) program, the largest P4P example in primary care
  • Performance initially improved in a stepwise fashion for incentivized areas of quality, but quickly regressed to pre-QOF rates of improvement after the first year of implementation. (i.e. Outcomes were slowly improving prior to QOF. Outcomes improved quickly during the initial QOF year. Thereafter, outcomes continued to improve, but as slowly as they had in the pre-QOF era)

Significance to Literature:

P4P evidence is mixed and difficult to analyze. New schemes must be designed from the beginning to better allow evaluation, including control and treatment groups coupled with before and after data. Evidence for rapid improvements in performance were observed for only the first year of QOF.

 

(414) Antos JR. If We Pay for Value, Will We Get It? J Ambul Care Manage. 2016 Apr-Jun;39(2):108-10. doi: 10.1097/JAC.0000000000000146.

PMID: 26945289

Summary:

  • An overview on the lack of agreement on what value in healthcare is, how to produce greater value, and how to identify when value has been achieved
  • Author points out how policy leaders often ignore the viewpoint of patients on what quality and value in healthcare looks like
  • This will become increasingly important as health insurance shifts more financial responsibility to consumers
  • Author also cautions against “measurement for measurement’s sake” due to the burden placed on providers and the potential shift in attention away from non-incentivized areas which may impact patient outcomes more significantly
  • The Incentivizing Health Care Quality Outcomes Act of 2014 attempts to combat this as it would “require Medicare to use a uniform outcome-based quality measurements system”, intending to “change the emphasis from measuring performance to producing value”

Significance to Literature:

It is becoming an increasingly important challenge to effectively “mesh the differing perspectives of payers, providers, and consumers on what constitutes value in healthcare”

 

Key Article

(420) Lin et al. Impact of pay for performance on behavior of primary care physicians and patient outcomes. J Evid Based Med. 2015 Dec 12. doi: 10.1111/jebm.12185. [Epub ahead of print].

PMID: 26667492

Summary:

  • Systematic review of 44 studies to assess the impact of P4P on primary care physician behavior and patient outcomes
  • Overall positive effect was found for the management of disease although process outcomes often improved more than endpoint outcomes
  • Baseline quality of medical care and the size of practice both limit performance improvement
  • Unintended consequences associated with P4P were found to include:
    • Rising medical costs for programs without financial metrics
    • Inconsistent effects on health equity - some programs improved and some programs exacerbated inequities related to sex, age, ethnicity, socioeconomic status, comorbidity/severity, duration of illness, and size of practice.
    • Inconsistency in patient satisfaction (some increased and some decreased patient satisfaction)

Significance to Literature:

Evidence for P4P has shown positive clinical effects for most diseases, but implementation may bring about negative unintended consequences, particularly related to health equity.

 

(424) Roland M. Does pay-for-performance in primary care save lives? Lancet. 2016 Jul 16;388(10041):217-218. doi: 10.1016/S0140-6736(16)00550-X. Epub 2016 May 17.

PMID: 27207745

Summary:

  • In response to Ryan and colleagues (425) study on the the long-term evidence for the impact of the United Kingdom’s nationwide P4P scheme, the Quality and Outcomes Framework (QOF), on mortality
  • Most studies on P4P show programs’ effects to be modest, with either a small-positive or no effect
  • Author advocates for the importance of a universal primary care system with a strong preventive medicine focus and for measures that reduce behaviors that lead to poor health and early death

Significance to Literature:

Components of the primary care system could have a more significant impact on outcomes than P4P alone

 

Key Article

(425) Ryan et al. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet. 2016 Jul 16;388(10041):268-274. doi: 10.1016/S0140-6736(16)00276-2. Epub 2016 May 17.

PMID: 27207746

Summary:

  • The United Kingdom’s (UK) Quality and Outcomes Framework (QOF), introduced in 2004, is the world’s largest primary care P4P program
  • Population-level mortality statistics from 1994-2010 for the UK and other high-income countries were assessed
  • Primary outcome was mortality per 100,000 population for “a composite outcome of disease areas that were targeted by the QOF from the beginning of the program”
  • Secondary outcomes included mortality for ischemic heart disease, cancer, and a composite of all causes of death not included in the primary outcome
  • No significant association with improved population mortality was found for any assessed disease area, both those targeted and not targeted by the QOF

Significance to Literature:

Results indicates that the viability of P4P to improve population mortality is questionable, and the comparison of the cost-effectiveness of P4P to other health system interventions is necessary

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