Early Experience With Pay-for-Performance: From Concept to Practice

Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass 02115, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 11/2005; 294(14):1788-93. DOI: 10.1001/jama.294.14.1788
Source: PubMed

ABSTRACT The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care.
To evaluate the impact of a prototypical physician pay-for-performance program on quality of care.
We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations.
Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.
Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.
Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline.

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Available from: Zhonghe Li, Aug 12, 2015
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    • "These employ the " expenditure " governing instrument (also called " treasure " ). One example is the family of pay-forperformance (P4P) experiments for physician services underway in such jurisdictions as the United Kingdom, United States, Australia and Ontario (Devlin et al. 2006; Doran et al. 2006; Epstein 2006; Pink et al. 2006; Rosenthal et al. 2005), which often tie funds to performance of desired activities (Marks et al. 2011). Another involves changes in the financial incentives for hospitals, including moves to activity-based funding (Chalkley and Malcomson 2000; Sutherland 2011; Sutherland et al. 2011). "
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    ABSTRACT: Accountability is a key component of healthcare reforms, in Canada and internationally, but there is increasing recognition that one size does not fit all. A more nuanced understanding begins with clarifying what is meant by accountability, including specifying for what, by whom, to whom and how. These papers arise from a Partnership for Health System Improvement (PHSI), funded by the Canadian Institutes of Health Research (CIHR), on approaches to accountability that examined accountability across multiple healthcare subsectors in Ontario. The partnership features collaboration among an interdisciplinary team, working with senior policy makers, to clarify what is known about best practices to achieve accountability under various circumstances. This paper presents our conceptual framework. It examines potential approaches (policy instruments) and postulates that their outcomes may vary by subsector depending upon (a) the policy goals being pursued, (b) governance/ownership structures and relationships and (c) the types of goods and services being delivered, and their production characteristics (e.g., contestability, measurability and complexity).
    09/2014; 10(SP):12-24. DOI:10.12927/hcpol.2014.23932
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    • "The best evidence to date on the effects of P4P programs are from two observational studies in the U.S. drawn from the P4P initiatives introduced by a large network Health Managed Organization (HMO): PacifiCare Health Plan. The first study (Rosenthal et al. 2005) examined the effect of Quality Incentive Programs (QIP) provided by PacifiCare Health Plan to medical groups in California in 2002 on physician delivery of cervical cancer screening, mammography and haemoglobin A1c test. It used a difference-in-difference design by comparing provider groups in California which were affected by these incentives with provider groups in the Pacific Northwest which were unaffected by the incentives but also contracted with PacifiCare Health Plan. "
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    ABSTRACT: This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care. Copyright © 2013 John Wiley & Sons, Ltd.
    Health Economics 08/2014; 23(8). DOI:10.1002/hec.2971 · 2.14 Impact Factor
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    • "This system facilitates a single quality measurement that distributes 1000 points across four domains (Roland 2004; Doran et al. 2006; Lester and Majeed 2008). In the United States, there are also systems of clinical indicators that measure outpatient care (Rosenthal et al. 2005; The Ambulatory Care Quality Alliance Recommended Starter Set). One of these systems is the Summary Quality Index (SQUID), a composite measure of the quality of primary care that consists of 36 quality indicators related to a variety of fields and supported by a solid scientific base (Nietert et al. 2007). "
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    ABSTRACT: The development of electronic medical records has allowed the creation of new quality indicators in healthcare. Among them, synthetic indicators facilitate global interpretation of results and comparisons between professionals. A healthcare quality standard (EQA, the Catalan acronym for Estàndard de Qualitat Assistencial) was constructed to serve as a synthetic indicator to measure the quality of care provided by primary care professionals in Catalonia (Spain). The project phases were to establish the reference population; select health problems to be included; define, select and deliberate about subindicators; and construct and publish the EQA. Construction of the EQA involved 107 healthcare professionals, and 91 health problems were included. In addition, 133 experts were consulted, who proposed a total of 339 indicators. After systematic paired comparison, 61 indicators were selected to create the synthetic indicator. The EQA is now calculated on a monthly basis for more than 8000 healthcare professionals using an automated process that extracts data from electronic medical records; results are published on a follow-up website. Along with the use of the online EQA results tool, there has been an ongoing improvement in most of the quality of care indicators. Creation of the EQA has proven to be useful for the measurement of the quality of care of primary care services. Also an improvement trend over 5 years is shown across most of the measured indicators. The online version of this article (doi:10.1186/2193-1801-2-51) contains supplementary material, which is available to authorized users.
    SpringerPlus 12/2013; 2(1):51. DOI:10.1186/2193-1801-2-51
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