Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial

BACKGROUND

Disparities in hypertension control are well documented but underaddressed.

METHODS

RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.

RESULTS

A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]).

CONCLUSIONS

Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

The Association of Guideline-Concordant Sentinel Lymph Node Biopsy for Melanoma at Minority-Serving Hospitals

BACKGROUND

Minority-serving hospitals (MSHs) have been associated with lower guideline adherence and worse outcomes for various cancers. However, the relationship among MSH status, concordance with sentinel lymph node biopsy (SLNB) guidelines, and overall survival (OS) for patients with cutaneous melanoma is not well studied.

METHODS

The National Cancer Database was queried for patients diagnosed with T1a*, T2, and T3 melanoma between 2012 and 2017. MSHs were defined as the top decile of institutions ranked by the proportion of minorities treated for melanoma. Based on National Comprehensive Cancer Network guidelines, guideline-concordant care (GCC) was defined as not undergoing SLNB if thickness was < 0.76 mm without ulceration, mitosis ≥ 1/mm², or lymphovascular invasion (T1a*), and performing SLNB for patients with intermediate thickness melanomas between 1.0 and 4.0 mm (T2/T3). Multivariable logistic regressions examined associations with GCC. The Kaplan-Meier method and log-rank tests were used to evaluate OS between MSH and non-MSH facilities.

RESULTS

Overall, 5.9% (N = 2182/36,934) of the overall cohort and 37.8% of minorities (n = 199/527) were managed at MSHs. GCC rates were 89.5% (n = 33,065/36,934) in the overall cohort and 85.4% (n = 450/527) in the minority subgroup. Patients in the overall cohort (odds ratio [OR] 0.85; p = 0.02) and the minority subgroup (OR 0.55; p = 0.02) were less likely to obtain GCC if they received their care at MSHs compared with non-MSHs. Minority patients receiving care at MSHs had a decreased survival compared with those treated at non-MSHs (p = 0.002).

CONCLUSIONS

Adherence to SLNB guidelines for melanoma was lower at MSHs. Continued focus is needed on equity in melanoma care for minority patients in the United States.

The role of pay-for-performance in reducing healthcare disparities: A narrative literature review

As American healthcare shifts to value-based payment, Pay-for-Performance (P4P) has become an important and controversial topic. One of the main controversies pertains to its potential to narrow or widen existing healthcare disparities depending on how the program is designed and implemented. It is thus imperative to understand which design features are most likely to reduce disparities. We conducted a systematic literature review from 2004 to 2021 of P4P's impact on disparities. Given the interdisciplinary nature of P4P research, multiple search strategies were combined, and many study designs were eligible for analysis. The literature was then qualitatively analyzed, with themes and major findings developed using Grounded Theory. Six major design features emerged as most promising in leveraging P4P to reduce disparities: 1) Risk/Case-Mix Adjustment; 2) Stratified Performance Measures/Stratification; 3) Disparity Reduction Metrics; 4) Exception Reporting; 5) Pay-for-Improvement; and 6) Population-Specific Metrics. Each design feature has its own mechanism, strengths, and weaknesses. We identify and define these features' direct and indirect effects on healthcare disparities. The interaction of each design feature with one another, with P4P as a whole, and within the larger reimbursement system can have considerable effects on disparities. Promising strategies exist to leverage P4P to narrow disparities for clinically and socially complex patients. The six design features discussed in this review help P4P programs address structural disadvantages faced by such patients and their providers. In regard to health equity, these design features can transform P4P from being part of the problem to being part of the solution.

Utilizing Implementation Science to Bridge Cerebrovascular Health Disparities: a Local to Global Perspective

PURPOSE OF REVIEW

Stroke is a prime example of a medical disorder whose incidence, prevalence, and outcomes are strongly characterized by health disparities across the globe. This scoping literature review seeks to depict how implementation science could be utilized to advance health equity in the prevention, acute treatment, and post-acute management of stroke in the underserved regions of high-income countries as well as in all low-income countries.

RECENT FINDINGS

A major reason for the persisting and widening cerebrovascular disease disparities is that evidence-based stroke prevention and treatment interventions have been differentially translated (if at all) to various populations and settings. The field of implementation science is endowed with frameworks, theories, methodological approaches, and outcome measures, including equity indices, which could be harnessed to facilitate the translation of evidence-based interventions into clinical practice for underserved and vulnerable communities. Encouragingly, there are several novel frameworks, which eminently merge implementation science constructs with health equity determinants, thereby opening up key opportunities to bridge burgeoning worldwide gaps in cerebrovascular health equity.

Did paying drugs misuse treatment providers for outcomes lead to unintended consequences for hospital admissions? Difference-in-differences analysis of a pay-for-performance scheme in England

AIMS

To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions.

DESIGN

A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression.

SETTING

Hospitals in all 149 organisational areas in England for the period 2009-2010 to 2015-2016.

PARTICIPANTS

572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD-10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas).

INTERVENTION AND COMPARATORS

Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non-re-presentation to treatment in the 12 months following completion.

MEASUREMENTS

Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation.

FINDINGS

For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses.

CONCLUSION

A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.

Association Between Federal Value-Based Incentive Programs and Health Care-Associated Infection Rates in Safety-Net and Non-Safety-Net Hospitals

IMPORTANCE

In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown.

OBJECTIVE

To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.

EXPOSURES

HACRP and HVBP implementation in fiscal year 2015 or 2016.

MAIN OUTCOMES AND MEASURES

The primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates.

RESULTS

Of the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).

CONCLUSIONS AND RELEVANCE

This study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.

Physician Incentives and Sex/Gender Differences in Depression Care: An Interrupted Time Series Analysis

Introduction: Physician incentives have been shown to reduce socioeconomic disparities in health care. The impact on sex/gender inequalities, however, has rarely been investigated. Using population-based data, this study investigated sex/gender differences in depression care and the impact of physician incentives.

Methods: Deidentified health data from physician claims, hospitals, vital statistics, prescription database, and insurance plan registries in British Columbia, Canada, were examined, retrospectively. Individuals with depression were identified and their use of mental health services was tracked for 12 months following initial diagnosis. The following indicators were assessed: (1) counseling/psychotherapy (CP), (2) minimally adequate counseling/psychotherapy (MACP), (3) antidepressant therapy (AT), and (4) minimally adequate antidepressant therapy (MAAT). Sex/gender differences in these indicators before (January 2005–December 2007) and after (January 2008–December 2012) the introduction of physician incentives were estimated using interrupted time series analysis.

Results: Preintervention, the percentage of individuals with depression who received CP was higher among males (CP: 58.4%, MACP: 13.6%) than females (CP: 57.1%, MACP: 10.9%). In contrast, the percentage who received AT was higher among females (AT: 57.7%, MAAT: 47.4%) than males (AT: 53.6%, MAAT: 41.9%). These statistically significant sex/gender differences remain unchanged postintervention.

Conclusions: Sex/gender differences in depression care persist despite the introduction of physician incentives.

Association of Hospital Racial Composition and Payer Mix With Mortality in Acute Coronary Syndrome

Background Patient characteristics insufficiently explain disparities in cardiovascular outcomes among hospitalized patients, suggesting a role for community or hospital-level factors. Here, we evaluate the association of hospital racial composition and payer mix with all-cause inpatient mortality for patients hospitalized with acute coronary syndrome (ACS). Methods and Results Using the National Inpatient Sample, we identified adult hospitalizations from 2014 with a primary diagnosis of ACS (n=550 005). We divided National Inpatient Sample hospitals into quartiles based on percent of minority (black, Hispanic, Asian or Pacific Islander, Native American race/ethnicity) and low-income payer (Medicaid or uninsured) discharges in 2014. We utilized logistic regression to determine whether hospital minority or low-income payer makeup associated with all-cause inpatient mortality among those admitted for ACS . In adjusted models, ACS patients admitted to hospitals with >12.4% to 25.4% (Quartile 2), >25.4% to 44.3% (Q3), and >44.3% (Q4) minority discharges experienced a 14% (OR 1.14, 95% CI 1.06-1.23), 13% (OR 1.13, 95% CI 1.04-1.23), and 15% (OR 1.15, 95% CI 1.04-1.26) increased odds of all-cause inpatient mortality compared with hospitals with ≤12.4% (Q1) minority discharges. ACS patients admitted to hospitals with >18.7% to 25.7% (Q2) and >34.0% (Q4) low-income payer discharges experienced a 9% (OR 1.09, 1.01-1.17) and 9% (OR 1.09, 1.00-1.19) increased odds of all-cause inpatient mortality when compared with hospitals with ≤18.7% (Q1) low-income payer discharges. Conclusions Hospital minority and low-income payer makeup positively associate with odds of all-cause inpatient mortality among patients admitted for acute coronary syndrome.

Economic Dimensions of Health Inequities: The Role of Implementation Research

Health inequities are well-documented, but their economic dimensions have received less attention. In this report, we describe four economic dimensions of health inequities in the United States. First, we describe an economic conceptual framework that connects poverty and health inequities at both individual and population levels and conveys the concept of reverse causality, where poverty worsens health inequities and health inequities worsen poverty. This framework can help us understand the key elements of health inequity and its drivers. Second, we describe economic measurements used for quantifying the economic burden of health inequalities and summarize the empirical findings from studies. Third, we review the evidence on the return-on-investment of economic interventions that are aimed at reducing health inequities. Finally, we highlight the importance of cross disciplinary perspectives from economics and implementation research in effectively delivering interventions that can mitigate health inequities.

Why Money Alone Can’t (Always) “Nudge” Physicians

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act

OBJECTIVE

Evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black patients and determine whether it produced risk selection.

DATA SOURCE/STUDY SETTING

Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels.

STUDY DESIGN

Nested study within a cluster randomized controlled trial of three types of financial incentives and no incentives (control). We compared the proportion of physicians' black patients meeting hypertension performance measures for baseline and final performance periods. We measured risk selection by comparing the proportion of patients who switched providers, patient visit frequency, and panel turnover. Due to limited power, we prespecified in the analysis plan combining the three incentive groups and oversampling black patients.

DATA COLLECTION/EXTRACTION METHOD

Data collected electronically and by chart review.

PRINCIPAL FINDINGS

The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final period was 6.3 percent (95 percent confidence interval, 0.8-11.7 percent) greater for physicians who received an incentive than for controls. There was no difference between intervention and controls in the proportion of patients who switched providers, visit frequency, or panel turnover.

CONCLUSIONS AND RELEVANCE

A pay-for-performance intervention improved blood pressure control or appropriate response to uncontrolled blood pressure in black patients and did not produce risk selection.

Pay-for-performance reduces healthcare spending and improves quality of care: Analysis of target and non-target obstetrics and gynecology surgeries

Objective

In Korea, the Value Incentive Program (VIP) was first applied to selected clinical conditions in 2007 to evaluate the performance of medical institutes. We examined whether the condition-specific performance of the VIP resulted in measurable improvement in quality of care and in reduced medical costs.

Design

Population-based retrospective observational study.

Setting

We used two data set including the results of quality assessment and hospitalization data from National Health Claim data from 2011 to 2014.

Participants

Participants who were admitted to the hospital for obstetrics and gynecology were included. A total of 535 289 hospitalizations were included in our analysis.

Methods

We used a generalized estimating equation (GEE) model to identify associations between the quality assessment and length of stay (LOS). A GEE model based on a gamma distribution was used to evaluate medical cost. The Poisson regression analysis was used to evaluate readmission.

Main Outcome Measures

The outcome variables included LOS, medical costs and readmission within 30 days.

Results

Higher condition-specific performance by VIP participants was associated with shorter LOSs, decreases in medical cost, and lower within 30-day readmission rates for target and non-target surgeries. LOS and readmission within 30 days were different by change in quality assessment at each medical institute.

Conclusions

Our findings contribute to the body of evidence used by policy-makers for expansion and development of the VIP. The study revealed the positive effects of quality assessment on quality of care. To reduce the between-institute quality gap, alternative strategies are needed for medical institutes that had low performance.

Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"?

BACKGROUND

Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators.

OBJECTIVE

In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion.

DESIGN

Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes.

PARTICIPANTS

All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009.

MAIN MEASURES

The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact.

KEY RESULTS

Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001).

CONCLUSIONS

These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.

Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update

Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.

The Quality of Surgical and Pneumonia Care in Minority-Serving and Racially Integrated Hospitals

OBJECTIVE

To explore the association between quality of care for surgical and pneumonia patients and the racial/ethnic composition of hospitals' patients.

DATA SOURCE

Our primary data were surgical and pneumonia processes of care indicators from the 2012 Medicare Hospital Compare Data. We merged this data with information from the 2011 American Hospital Association Annual Survey of Hospitals. We computed the racial and ethnic composition of hospital patients using 2008 data from the Healthcare Costs and Utilization Project.

STUDY DESIGN

The sample included 1,198 acute care general hospitals from 11 states: AZ, CA, FL, IA, MA, MD, NC, NJ, NY, WA, and WI. We compared quality across minority-serving, racially integrated, and majority-white hospitals using unconditional quantile regression models controlling for hospital and market characteristics.

PRINCIPAL FINDINGS

We found quality differences between the lowest performing minority-serving, racially integrated, and majority-white hospitals. As we moved from 10th to 90th quantile, the quality differences between hospitals by patients' racial composition disappeared. In other words, the best minority-serving and racially integrated hospitals performed as well as the best majority hospitals.

CONCLUSIONS

Efforts to improve quality of care for patients in minority-serving and racially integrated hospitals should focus on the lowest performers.

Differences in the rates of patient safety events by payer: implications for providers and policymakers

BACKGROUND

The reduction of adverse patient safety events and the equitable treatment of patients in hospitals are clinical and policy priorities. Health services researchers have identified disparities in the quality of care provided to patients, both by demographic characteristics and insurance status. However, less is known about the extent to which disparities reflect differences in the places where patients obtain care, versus disparities in the quality of care provided to different groups of patients in the same hospital.

OBJECTIVE

In this study, we examine whether the rate of adverse patient safety events differs by the insurance status of patients within the same hospital.

METHODS

Using discharge data from hospitals in 11 states, we compared risk-adjusted rates for 13 AHRQ Patient Safety Indicators by Medicare, Medicaid, and Private payer insurance status, within the same hospitals. We used multivariate regression to assess the relationship between insurance status and rates of adverse patient safety events within hospitals.

RESULTS

Medicare and Medicaid patients experienced significantly more adverse safety events than private pay patients for 12 and 7 Patient Safety Indicators, respectively (at P < 0.05 or better). However, Medicaid patients had significantly lower event rates than private payers on 2 Patient Safety Indicators.

CONCLUSIONS

Risk-adjusted Patient Safety Indicator rates varied with patients' insurance within the same hospital. More research is needed to determine the cause of differences in care quality received by patients at the same hospital, especially if quality measures are to be used for payment.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Therapeutic inferences for individual patients

RATIONALE, AIMS AND OBJECTIVES

Increased awareness of the gap between controlled research and medical practice has raised concerns over whether the special attention of doctors to probability estimates from clinical trials really improves the care of individuals. Evidence-based medicine has acknowledged that research results are not applicable to all kinds of patients, and consequently, has attempted to overcome this limitation by introducing improvements in the design and analysis of clinical trials.

METHODS

A clinical case is used to highlight the premises required to support reasonable extrapolations from controlled research to individuals. Then, the prospects of two key methodological improvements - pragmatic randomized controlled trials and subgroup analysis - are critically appraised.

RESULTS

A principle to guide therapeutic inferences is suggested. According to this principle, the probabilities of interest for purposes of therapeutic decision making are those of the set defined by everything that is relevant to the patient and the outcome of interest at the time of the decision. It is argued that the conditions necessary to authorize automatic extrapolations of research results to specific patients are highly demanding. Furthermore, these requirements are rarely accomplished in real practice, even in the event that probability estimates come from samples generally taken as representative and are derived from specific subsets of patients.

CONCLUSIONS

Clinicians should generally avoid unreflective extrapolations from research and address, as explicitly as possible, the challenge of estimating probabilities for individual patients. A key element of this task is the integration of data from research and non-research sources.

The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme

Objectives

Performance measurement systems are increasingly used to reward and improve provider performance. However, such initiatives may also inadvertently induce a range of unintended and dysfunctional side-effects. This study explores the unintended and adverse consequences induced by the Iranian national hospital grading programme, which incorporates financial incentives for meeting nationally defined standards.

Methods

We interviewed key informants across four key groups with a legitimate interest in healthcare performance: four purposively selected hospitals; four health insurance organizations; the Iranian hospital accreditation body; and one grading agency. The transcribed interviews and field notes were analysed thematically, and subsequently, member checking was conducted.

Results

Seven dysfunctional consequences were identified: misrepresentation of data by hospitals; increased anxiety and stress among hospital employees; tunnel vision; financial pressures on poorly graded hospitals; incentives to purchase unnecessary equipment; erosion of public trust; and restricting access to hospital services by patients. These were caused by the way the grading system was implemented: poor standards of audit; the way in which the audit process was conducted; and the timing of audits. The pay for performance element of the grading system and the focus on structural aspects in the standards made improvement in grading particularly difficult for those hospitals that had been assessed as under-performing.

Conclusion

Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.

Healthcare reimbursement models and orthopaedic trauma: will there be change in patient management? A survey of orthopaedic surgeons

OBJECTIVES

Healthcare reimbursement models are changing. Fee-for-service may be replaced by pay-for-performance or capitated care. The purpose of this study was to examine the potential changes in orthopaedic trauma surgery patient management based on potential shifts in policy surrounding readmission and reimbursement.

METHODS

An e-mail survey consisting of 3 case-based scenarios was delivered to 375 orthopaedic surgeons. Five options for management of each case were provided. Each of the 3 cases was presented in 3 different healthcare settings: scenario A, our current healthcare setting; scenario B, in which 90-day reoperation or readmission would not be reimbursed; and scenario C, in which a capitated healthcare structure paid a fixed amount per patient.

RESULTS

The response rate was 40.3% with 151 surgeons completing the survey. A 71.1% of the respondents were in private practice settings, whereas 28.3% were in academic centers. In each case, there was significant increase in the respondents' choice to transfer patients to tertiary care centers under both the capitated and penalization systems as compared with the current fee-for-service model.

CONCLUSIONS

This survey is the first of its kind to demonstrate through case-based scenarios that a healthcare system with readmission penalties and capitated reimbursement models may lead to a significant increase in transfer of complex orthopaedic trauma patients to tertiary care centers. Physicians should be encouraged to continue evidence-based medicine instead of making decisions due to finances, and other avenues of healthcare savings should be explored to decrease patient transfer rates with healthcare changes.

Evolving provider payment models and patient access to innovative medical technology

Abstract Objective: To investigate the evolving use and expected impact of pay-for-performance (P4P) and risk-based provider reimbursement on patient access to innovative medical technology.

METHODS

Structured interviews with leading private payers representing over 110 million commercially-insured lives exploring current and planned use of P4P provider payment models, evidence requirements for technology assessment and new technology coverage, and the evolving relationship between the two topics.

RESULTS

Respondents reported rapid increases in the use of P4P and risk-sharing programs, with roughly half of commercial lives affected 3 years ago, just under two-thirds today, and an expected three-quarters in 3 years. All reported well-established systems for evaluating new technology coverage. Five of nine reported becoming more selective in the past 3 years in approving new technologies; four anticipated that in the next 3 years there will be a higher evidence requirement for new technology access. Similarly, four expected it will become more difficult for clinically appropriate but costly technologies to gain coverage. All reported planning to rely more on these types of provider payment incentives to control costs, but didn't see them as a substitute for payer technology reviews and coverage limitations; they each have a role to play.

LIMITATIONS

Interviews limited to nine leading payers with models in place; self-reported data.

CONCLUSION

Likely implications include a more uncertain payment environment for providers, and indirectly for innovative medical technology and future investment, greater reliance on quality and financial metrics, and increased evidence requirements for favorable coverage and utilization decisions. Increasing provider financial risk may challenge the traditional technology adoption paradigm, where payers assumed a 'gatekeeping' role and providers a countervailing patient advocacy role with regard to access to new technology. Increased provider financial risk may result in an additional hurdle to the adoption of new technology, rather than substitution of provider- for payer-based gatekeeping.

Key issues in the design of pay for performance programs

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages "selection" and "teaching to the test" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally "decoupled" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.

Effect of nonpayment for preventable infections in U.S. hospitals

BACKGROUND

In October 2008, the Centers for Medicare and Medicaid Services (CMS) discontinued additional payments for certain hospital-acquired conditions that were deemed preventable. The effect of this policy on rates of health care-associated infections is unknown.

METHODS

Using a quasi-experimental design with interrupted time series with comparison series, we examined changes in trends of two health care-associated infections that were targeted by the CMS policy (central catheter-associated bloodstream infections and catheter-associated urinary tract infections) as compared with an outcome that was not targeted by the policy (ventilator-associated pneumonia). Hospitals participating in the National Healthcare Safety Network and reporting data on at least one health care-associated infection before the onset of the policy were eligible to participate. Data from January 2006 through March 2011 were included. We used regression models to measure the effect of the policy on changes in infection rates, adjusting for baseline trends.

RESULTS

A total of 398 hospitals or health systems contributed 14,817 to 28,339 hospital unit-months, depending on the type of infection. We observed decreasing secular trends for both targeted and nontargeted infections long before the policy was implemented. There were no significant changes in quarterly rates of central catheter-associated bloodstream infections (incidence-rate ratio in the postimplementation vs. preimplementation period, 1.00; P=0.97), catheter-associated urinary tract infections (incidence-rate ratio, 1.03; P=0.08), or ventilator-associated pneumonia (incidence-rate ratio, 0.99; P=0.52) after the policy implementation. Our findings did not differ for hospitals in states without mandatory reporting, nor did it differ according to the quartile of percentage of Medicare admissions or hospital size, type of ownership, or teaching status.

CONCLUSIONS

We found no evidence that the 2008 CMS policy to reduce payments for central catheter-associated bloodstream infections and catheter-associated urinary tract infections had any measurable effect on infection rates in U.S. hospitals. (Funded by the Agency for Healthcare Research and Quality.).

Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures?

BACKGROUND

Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs.

OBJECTIVE

To examine the association between PO location and P4P performance.

DESIGN

Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S.

PARTICIPANTS

160 POs participating in 2009.

MAIN MEASURES

We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use.

KEY RESULTS

The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001).

CONCLUSIONS

Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.

The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences

In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data. Participants' descriptions of unintended impacts of the policy centered around three themes. Results suggest the policy has focused more attention on targeted HAIs and has affected hospital staff; relatively fewer systems changes have ensued. Some consequences of the policy, such as infection preventionists having less time to devote to HAIs other than those in the policy or having less time to implement prevention activities, may have undesirable effects on HAI rates if hospitals do not recognize and react to potential time and resource gaps.

Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives

BACKGROUND

Reducing readmissions for heart failure is an important goal for policymakers. Current national policies financially penalize hospitals with high readmission rates, which may have unintended consequences if these institutions are resource-poor, either financially or clinically.

METHODS AND RESULTS

We analyzed national claims data for Medicare patients with heart failure discharged from US hospitals in 2006 to 2007. We used multivariable models to examine hospital characteristics, 30-day all-cause readmission rates, and likelihood of performing in the worst quartile of readmission rates nationally. Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001). Patients discharged from hospitals without cardiac services (27.2%) had higher readmission rates than those from hospitals with full cardiac services (25.1%, P<0.001); patients discharged from hospitals in the lowest quartile of nurse staffing (28.5%) had higher readmission rates than those from hospitals in the highest quartile (25.4%, P<0.001). Patients discharged from small hospitals (28.4%) had higher readmission rates than those discharged from large hospitals (25.2%, P<0.001). These same characteristics identified hospitals that were likely to perform in the worst quartile nationally.

CONCLUSIONS

Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates. As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.

Improving timely childhood immunizations through pay for performance in Medicaid-managed care

OBJECTIVE

To evaluate the impact of a "piece-rate" pay-for-performance (P4P) program aimed at rewarding up-to-date immunization delivery to 2-year-olds according to the recommended series.

DATA SOURCES/STUDY SETTING

Plan-level data from New York State's Quality Assurance Reporting Requirement and claims data from Hudson Health Plan for 2003-2007. In 2003 Hudson Health Plan, a not-for-profit Medicaid-focused managed care plan, introduced a U.S.$200 bonus payment for each fully immunized 2-year-old and provided administrative supports for identifying children who may need immunization. This represented a potential bonus of 15-25 percent above base reimbursement for eligible 2-year-olds.

STUDY DESIGN

Case-comparison and interrupted times series.

PRINCIPAL FINDINGS

Immunization rates within Hudson Health Plan rose at a significantly, albeit modestly, higher rate than the robust secular trend noted among comparison health plans. Supplementary analyses suggest that there was no significant change in preexisting disparities during the study period, and that children with chronic conditions have significantly greater odds of being fully immunized during the entire study period.

CONCLUSIONS

This study suggests that a piece-rate P4P program with appropriate administrative supports can be effective at improving childhood immunization rates.

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.

A review of the evidence for disparities in child vs adult health care: a disparity in disparities

Racial and ethnic health disparities in primary care have been well documented in the US healthcare system. However, very little attention has been directed toward inequities in child health. The aim of this review is to provide context for the scope of the challenges associated with addressing pediatric health disparities in primary care by comparing the weight of evidence regarding racial/ethnic health disparities for children vs adults. A multisystem health disparities conceptual model will frame the search strategy and analysis of the review. This paper will: (1) identify knowledge deficits in the understanding of existing disparities in pediatric primary care relative to adult primary care; (2) assess root causes of disparities for children vs adults; and (3) propose recommendations for a research agenda and policy implementation to eliminate disparities in pediatric primary care.

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Impact of pay for performance on inequalities in health care: systematic review

OBJECTIVES

To assess the impact of pay for performance programmes on inequalities in the quality of health care in relation to age, sex, ethnicity and socioeconomic status.

METHODS

Systematic search and appraisal of experimental or observational studies that assessed quantitatively the impact of a monetary incentive on health care inequalities. We searched published articles in English identified in the MEDLINE, EMBASE, PsycINFO and Cochrane databases.

RESULTS

Twenty-two studies were identified, 20 of which were conducted in the United Kingdom and examined the impact of the Quality and Outcomes Framework. Sixteen studies used practice level data rather than patient level data. Socioeconomic status was the most frequently examined inequality; age, sex and ethnic inequalities were less frequently assessed. There was some weak evidence that the use of financial incentives reduced inequalities in chronic disease management between socioeconomic groups. Inequalities in chronic disease management between age, sex and ethnic groups persisted after the use of such incentives.

CONCLUSION

Inequalities in chronic disease management have largely persisted after the introduction of the Quality and Outcome Framework. Pay for performance programmes should be designed to reduce inequalities as well as improve the overall quality of care.

The intended and unintended consequences of clinical guidelines

OBJECTIVES

First, we examine whether clinical guidelines, designed to improve health care and reduce disparities in clinical practice, are achieving their intended consequences. Second, we contemplate potential unintended consequences of clinical guidelines.

METHOD

As part of a factorial experiment we presented primary care doctors (n = 192) with clinically authentic vignettes of a 'patient' with already diagnosed diabetes with an emerging foot neuropathy. Their proposed clinical actions were compared with established practice guidelines for this clinical situation.

RESULTS

After establishing the existence of consistent socioeconomic disparities in the proposed management of the case presented, we found that reported use of practice guidelines had no measurable effect towards their reduction (one intended consequence). However, the reported use of practice guidelines appeared to precipitate more clinical actions, without eliminating documented disparities.

CONCLUSIONS

Consistent with other research we find that clinical practice guidelines are not producing a principal intended result, and may even produce unintended consequences.

Healthcare quality measurement in orthopaedic surgery: current state of the art

Improving quality of care in arthroplasty is of increasing importance to payors, hospitals, surgeons, and patients. Efforts to compel improvement have traditionally focused measurement and reporting of data describing structural factors, care processes (or 'quality measures'), and clinical outcomes. Reporting structural measures (eg, surgical case volume) has been used with varying degrees of success. Care process measures, exemplified by initiatives such as the Surgical Care Improvement Project measures, are chosen based on the strength of randomized trial evidence linking the process to improved outcomes. However, evidence linking improved performance on Surgical Care Improvement Project measures with improved outcomes is limited. Outcome measures in surgery are of increasing importance as an approach to compel care improvement with prominent examples represented by the National Surgical Quality Improvement Project. Although outcomes-focused approaches are often costly, when linked to active benchmarking and collaborative activities, they may improve care broadly. Moreover, implementation of computerized data systems collecting information formerly collected on paper only will facilitate benchmarking. In the end, care will only be improved if these data are used to define methods for innovating care systems that deliver better outcomes at lower or equivalent costs.

Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities

The 2001 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care pointed out extensive healthcare disparities in the United States even when controlling for disease severity, socioeconomic status, education, and access. The literature identifies several groups of Americans who receive disparate healthcare: ethnic minorities, women, children, the elderly, the handicapped, the poor, prisoners, lesbians, gays, and the transgender population. Disparate healthcare represents an enormous current challenge with substantial moral, ethical, political, public health, public policy, and economic implications, all of which are likely to worsen over the next several decades without immediate and comprehensive action. A review of recent literature reveals over 100 general and specific suggestions and solutions to eliminate healthcare disparities. While healthcare disparities have roots in multiple sources, racial stereotypes and biases remain a major contributing factor and are prototypical of biases based on age, physical handicap, socioeconomic status, religion, sexual orientation or other differences. Given that such disparities have a strong basis in racial biases, and that the principles of racism are similar to those of other "isms", we summarize the current state of healthcare disparities, the goals of their eradication, and the various potential solutions from a conceptual model of racism affecting patients (internalized racism), caregivers (personally mediated racism), and society (institutionalized racism).

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

PURPOSE

We undertook an in-depth exploration of the unintended consequences of pay-for-performance programs In England and California.

METHODS

We interviewed primary care physicians in California (20) and England (20) and compared unintended consequences in each setting. Interview recordings were transcribed verbatim and subjected to thematic analysis.

RESULTS

Unintended consequences reported by physicians varied according to the incentive program. English physicians were much more likely to report that the program changed the nature of the office visit. This change was linked to a larger number of performance measures and heavy reliance on electronic medical records, with computer prompts to facilitate the delivery of performance measures. Californian physicians were more likely to express resentment about pay for performance and appeared less motivated to act on financial incentives, even in the program with the highest rewards. The inability of Californian physicians to exclude individual patients from performance calculations caused frustration, and some physicians reported such undesirable behaviors as forced disenrollment of noncompliant patients. English physicians are assessed using data extracted from their own medical records, whereas in California assessment mostly relies on data collected by multiple third parties that may have different quality targets. Assessing performance based on these data contributes to feelings of resentment, lack of understanding, and lack of ownership reported by Californian physicians.

CONCLUSIONS

Our study findings suggest that unintended consequences of incentive programs relate to the way in which these programs are designed and implemented. Although unintended, these consequences are not necessarily unpredictable. When designing incentive schemes, more attention needs to be paid to factors likely to produce unintended consequences.