Pay for performance in primary care in England and California: comparison of unintended consequences

Benefits and costs of pay for performance as perceived by residents: a qualitative study

PURPOSE

To describe and interpret pay-for-performance (P4P) systems as perceived by internal medicine residents to develop curricula that relate P4P measures to quality improvement initiatives.

METHOD

In 2008-2009, the authors conducted a qualitative study in which 97 internal medicine residents completed a mandatory survey soliciting their views of the advantages and disadvantages of P4P. The authors analyzed responses to identify and categorize emergent themes.

RESULTS

Eighty-two residents (85%) noted advantages, from which 13 themes emerged. Two were general themes: P4P improves overall delivery of quality care by enabling quality care and by motivating providers to improve or provide quality care. The other themes formed three categories: P4P enables contemplation and knowledge enhancement (e.g., by promoting reflection) and has potential impacts both on physicians' delivery of better care (e.g., by facilitating vigilance and closer follow-up) and on the care delivery process (e.g., by increasing pay/satisfaction). Eighty-seven residents (90%) indicated disadvantages, from which 16 themes emerged. The four categories of the themes reflected P4P's impacts on patient perceptions (e.g., by decreasing patient satisfaction and access), on clinical care (e.g., by fostering abuse/gaming and compromising focus, care, and safety), on resources and efficiency, and on providers that may undermine morale.

CONCLUSIONS

Residents' reported advantages and disadvantages were often in direct opposition to each other (e.g., P4P enables quality care but also compromises focus, care, and safety). These opposing responses form a continuum that the authors believe will require providers to perform a balancing act to practice successfully in a P4P environment.

Organizações de saúde intensivas em conhecimento: um estudo no contexto de serviços de alta complexidade

O objetivo deste estudo é identificar elementos críticos de gestão para promover a transformação de uma organização tradicional para uma organização de aprendizagem em serviços de alta complexidade em saúde. Assume-se que as organizações tradicionais são aquelas gerenciadas com ênfase na informação, e as organizações de aprendizagem são aquelas gerenciadas com ênfase no desenvolvimento de conhecimento. O conhecimento organizacional é reconhecido como um dos recursos de grande valor estratégico para a prestação de serviços de alta complexidade. A análise da gestão em serviços de saúde intensivos em conhecimento está estruturada a partir da qualificação do processo assistencial, o qual engloba as etapas de acesso, da permanência e da continuidade do tratamento. Realizou-se um estudo de caso em um hospital privado do Rio Grande do Sul, cuja estratégia de diferenciação é atuar na resolução de problemas de alta complexidade. Entre os elementos gerenciais críticos evidenciados salientam-se: que o paciente precisa ser compreendido como cliente; que o vínculo com a instituição não termina no final do atendimento hospitalar, mas somente na resolução do problema enfrentado com a doença; e que as especialidades precisam estar harmonizadas e dispostas a compartilhar conhecimento, impulsionadas por protocolos assistenciais reconhecidos por todos.

Developing a policy-relevant research agenda for the patient-centered medical home: a focus on outcomes

BACKGROUND

The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions.

METHODS

In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health.

RESULTS

As a framework for our discussion, we have chosen the Institute of Medicine's six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences.

CONCLUSION

Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.

The unintended consequences of quality improvement

PURPOSE OF REVIEW

The focus on quality improvement has led to several types of initiatives in pediatric care; however, these programs may lead to potential unintended consequences.

RECENT FINDINGS

Unintended consequences of quality improvement programs that have been described are reviewed. Unintended effects on resource utilization include effects on costs, as well as the inability to apply programs across different populations and affect disparities in care. Unintended effects on provider behavior include measurement fixation behavior, as well as 'crowding out' behavior, in which gains in quality in one area may simply occur at the expense of quality of care in another. Patient preferences may not always match specific quality improvement measures. Unintended effects for patients may include decreased patient satisfaction, trust, or confidence in their provider.

SUMMARY

Recognition and anticipation of the possible unintended consequences of guideline implementation is a critical step to harnessing all the benefits of quality improvement in practice.

Effects of pay for performance on the quality of primary care in England

BACKGROUND

A pay-for-performance scheme based on meeting targets for the quality of clinical care was introduced to family practice in England in 2004.

METHODS

We conducted an interrupted time-series analysis of the quality of care in 42 representative family practices, with data collected at two time points before implementation of the scheme (1998 and 2003) and at two time points after implementation (2005 and 2007). At each time point, data on the care of patients with asthma, diabetes, or coronary heart disease were extracted from medical records; data on patients' perceptions of access to care, continuity of care, and interpersonal aspects of care were collected from questionnaires. The analysis included aspects of care that were and those that were not associated with incentives.

RESULTS

Between 2003 and 2005, the rate of improvement in the quality of care increased for asthma and diabetes (P<0.001) but not for heart disease. By 2007, the rate of improvement had slowed for all three conditions (P<0.001), and the quality of those aspects of care that were not associated with an incentive had declined for patients with asthma or heart disease. As compared with the period before the pay-for-performance scheme was introduced, the improvement rate after 2005 was unchanged for asthma or diabetes and was reduced for heart disease (P=0.02). No significant changes were seen in patients' reports on access to care or on interpersonal aspects of care. The level of the continuity of care, which had been constant, showed a reduction immediately after the introduction of the pay-for-performance scheme (P<0.001) and then continued at that reduced level.

CONCLUSIONS

Against a background of increases in the quality of care before the pay-for-performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme.