Effect of physician-specific pay-for-performance incentives in a large group practice.
ABSTRACT To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice.
In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance.
We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives.
Eight of 9 reported and incentivized measures showed significant improvement in 2007 compared with 2006. Three measures showed an improvement trend significantly better than the previous year's trend. A similar improvement trend was observed in 1 related measure that was reported but was nonincentivized. However, the improvement trend of Palo Alto Medical Clinic was not consistently different from that of the other 2 physician groups.
Small financial incentives (maximum, $5000/year) based on individual physicians' performance may have led to continued or enhanced improvement in well-established ambulatory care measures. Compared with other quality improvement programs having alternative foci for incentives (eg, increasing support for staff hours), the effect of physician-specific incentives was not evident.
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ABSTRACT: Pay for performance (P4P) schemes have become increasingly popular innovations in primary care and have generated questions about their effect on improving quality of care. To provide a brief outline of the international evidence on the relationship between P4P schemes and quality improvement. We conducted a literature search using relevant databases and reference lists of retrieved articles which discussed P4P schemes, quality in primary care and the Quality and Outcomes Framework (QOF). These included two recent systematic reviews of P4P schemes. Evidence on the effect of P4P on quality is limited. What we can say is that P4P schemes can have an effect on the behaviour of physicians and can lead to better clinical management of disease, but that there is cause for concern about the impact on the quality of care. P4P schemes need to take more account of broader definitions of quality, as whilst they can have a positive impact on incentivised clinical processes, it is not clear that this translates into improving the experience and outcome of care.Quality in primary care 01/2010; 18(2):111-6.
Article: Using the lessons of behavioral economics to design more effective pay-for-performance programs.[show abstract] [hide abstract]
ABSTRACT: To describe improvements in the design of pay-for-performance (P4P) programs that reflect the psychology of how people respond to incentives. Investigation of the behavioral economics literature. We describe 7 ways to improve P4P program design in terms of frequency and types of incentive payments. After discussing why P4P incentives can have unintended adverse consequences, we outline potential ways to mitigate these. Although P4P incentives are increasingly popular, the healthcare literature shows that these have had minimal effect. Design improvements in P4P programs can enhance their effectiveness. Lessons from behavioral economics may greatly enhance the design and effectiveness of P4P programs in healthcare, but future work is needed to demonstrate this empirically.The American journal of managed care 07/2010; 16(7):497-503. · 2.46 Impact Factor
Article: Systematic review: Effects, design choices, and context of pay-for-performance in health care.[show abstract] [hide abstract]
ABSTRACT: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness. The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers. One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level. P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.BMC Health Services Research 01/2010; 10:247. · 1.66 Impact Factor