A behavioral model of clinician responses to incentives to improve quality

A conceptual framework for evaluation of community pharmacy pay-for-performance programs

BACKGROUND

Recent interest in initiating pay-for-performance (P4P) programs indicates an underlying belief that economic incentives will have a direct impact on health care quality and efficiency. Evaluations of the impact of P4P programs on health care organizations and providers have been presented in the literature; however, none have focused on the impact of an incentive targeting community pharmacies.

OBJECTIVE

To propose a theory-derived conceptual framework of how a financial incentive might work in a community pharmacy.

METHODS

Studies from the fields of economics (agency theory), psychology (intrinsic and extrinsic motivators; expectancy theory), and organizational theory (ownership, institutional layers, organizational culture, and change management; quality improvement) were reviewed to inform the framework's components. This proposed conceptual framework also integrated and expanded on previous health care-related P4P models.

RESULTS

P4P programs inherently use financial incentives to catalyze change; however, elements from psychology and organizational theories along with economic theory were identified as important considerations in how a financial incentive may operate when targeting a community pharmacy. Through the incorporation of these theories along with other P4P frameworks in health care, a conceptual framework was derived comprising 4 domains: incentive, pharmacy, other influencing factors, and P4P program measures. Hypothesized relationships among these domains were depicted.

CONCLUSION

As focus on improving the quality of health care provision develops, opportunities for pharmacists to provide patient care services beyond dispensing will continue to advance, along with expanded reimbursement mechanisms extending beyond traditional product dispensing. The proposed theory-derived conceptual framework serves to depict how the integration of P4P and other factors may affect the pharmacy environment and subsequently affect a pharmacy's capability to perform well on medication-related quality measures. This framework may be used as a foundation on which to design studies to investigate the association between community pharmacy factors and performance in a P4P program.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists

BACKGROUND

Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting.

METHODS

We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention.

RESULTS

Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation.

CONCLUSIONS

Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Improving quality and performance in substance use treatment programs: What is being done and why is it so hard?

SUMMARY

As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12).

FINDINGS

Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control.

APPLICATIONS

Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.

Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis

BACKGROUND

Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs).

OBJECTIVE

To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs.

DESIGN

Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data.

SUBJECTS

Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider.

INTERVENTIONS

(1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues.

MAIN MEASURES

Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

KEY RESULTS

Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events.

CONCLUSIONS

Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

Value-based provider payment: towards a theoretically preferred design

Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by 'value', however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at: (1) identifying value dimensions that are ideally stimulated by VBP and (2) constructing a framework of a theoretically preferred VBP design. Based on a synthesis of both theoretical and empirical studies on payment incentives, we conclude that VBP should consist of two components: a relatively large base payment that implicitly stimulates value and a relatively small payment that explicitly rewards measurable aspects of value (pay-for-performance). Being the largest component, the base payment design is essential, but often neglected when it comes to VBP reform. We explain that this base payment ideally (1) is paid to a multidisciplinary provider group (2) for a cohesive set of care activities for a predefined population, (3) is fixed, (4) is adjusted for the population's risk profile and (5) includes risk-mitigating measures. Finally, some important trade-offs in the practical operationalisation of VBP are discussed.

Managerial strategies to make incentives meaningful and motivating

Purpose

Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care.

Design/methodology/approach

The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data.

Findings

The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers’ strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements.

Originality/value

Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers’ multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.

Qualitative analysis of direction of public hospital reforms in China

Reforms in public hospitals are among the most important improvements in China's health care system over the last two decades. However, the reforms that should be implemented in public hospitals are unclear. Thus, a feasible direction of reforms in Chinese public hospitals is suggested and reliable policy suggestions are provided for the government to reform public hospitals. The data used in this study were mainly derived from a qualitative study. Focus group discussions and in-depth interviews were conducted in Shanghai, Guangdong, and Gansu between May and December 2014. Government funding accounted for approximately eight percent of the total annual revenue of public hospitals in China, and the insufficient government subsidy considerably affects the operation mechanism of public hospitals. However, solely increasing this subsidy cannot address the inappropriate incentives of public hospitals in China. The most crucial step in setting the direction of reforms in public hospitals in China is transforming inappropriate incentives by implementing a new evaluation index system for directors and physicians in public hospitals.

Characterization and effectiveness of pay-for-performance in ophthalmology: a systematic review

Background

To identify, characterize and compare existing pay-for-performance approaches and their impact on the quality of care and efficiency in ophthalmology.

Methods

A systematic evidence-based review was conducted. English, French and German written literature published between 2000 and 2015 were searched in the following databases: Medline (via PubMed), NCBI web site, Scopus, Web of Knowledge, Econlit and the Cochrane Library. Empirical as well as descriptive articles were included. Controlled clinical trials, meta-analyses, randomized controlled studies as well as observational studies were included as empirical articles. Systematic characterization of identified pay-for-performance approaches (P4P approaches) was conducted according to the “Model for Implementing and Monitoring Incentives for Quality” (MIMIQ). Methodological quality of empirical articles was assessed according to the Critical Appraisal Skills Programme (CASP) checklists.

Results

Overall, 13 relevant articles were included. Eleven articles were descriptive and two articles included empirical analyses. Based on these articles, four different pay-for-performance approaches implemented in the United States were identified. With regard to quality and incentive elements, systematic comparison showed numerous differences between P4P approaches. Empirical studies showed isolated cost or quality effects, while a simultaneous examination of these effects was missing.

Conclusion

Research results show that experiences with pay-for-performance approaches in ophthalmology are limited. Identified approaches differ with regard to quality and incentive elements restricting comparability. Two empirical studies are insufficient to draw strong conclusions about the effectiveness and efficiency of these approaches.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2333-x) contains supplementary material, which is available to authorized users.

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.

Differences in Hospital Risk-standardized Mortality Rates for Acute Myocardial Infarction When Assessed Using Transferred and Nontransferred Patients

BACKGROUND

One in 5 patients with acute myocardial infarction (AMI) are transferred between hospitals. However, current hospital performance measures based on AMI mortality exclude these patients from the evaluation of referral hospitals.

OBJECTIVE

To determine the relationship between risk-standardized mortality for transferred and nontransferred patients at referral hospitals.

RESEARCH DESIGN

This is a retrospective cohort study.

SUBJECTS

Fee-for-service Medicare claims from 2011 for patients hospitalized with a primary diagnosis of AMI, at hospitals admitting at least 15 patients in transfer.

MEASURES

Hospital-specific risk-standardized 30-day mortality rates (RSMRs) for 2 groups of patients: those admitted through transfer from another hospital, and those natively admitted without a preceding or subsequent interhospital transfer.

RESULTS

There were 304 hospitals admitting at least 15 patients in transfer. These hospitals cared for 77,711 natively admitted patients (median, 254; interquartile range, 162-321), and 11,829 patients admitted in transfer (median, 26; interquartile range, 19-46). Risk-standardized mortality rates were higher for natively admitted patients than for those admitted in transfer (mean, 11.5%±1.2% vs. 7.2%±1.1%). There was weak correlation between hospital performance as assessed by RSMR for patients natively admitted versus those admitted in transfer (Pearson r=0.24, P<0.001); when performance was arrayed by quartile, 102 hospitals (33.6%) differed at least 2 quartiles of performance across the 2 patient groups.

CONCLUSIONS

For Medicare patients with AMI, hospital-specific RSMRs for natively admitted patients are only weakly associated with RSMRs for patients transferred in from another hospital. Current AMI performance metrics may fail to provide guidance about hospital quality for transferred patients.

The Impact of a Pay-for-Performance Program on Central Line-Associated Blood Stream Infections in Pennsylvania

Healthcare associated infections have significantly contributed to the rising cost of hospital care in the United States. The implementation of pay-for-performance (P4P) programs has been one approach to improve quality at a reduced cost. We quantify the impact of Highmark's Quality Blue (QB) hospital P4P program on central line-associated blood stream infections (CLABSI) in Pennsylvania. The impact of years of participation in QB on CLABSI is also evaluated. Data from 149 Pennsylvania hospitals on CLABSI from 2008-2013 are used. Negative binomial regression and fixed effects panel regression are performed. Hospitals participating in QB have 0.727 times the CLABSI as those hospitals that do not participate. Hospitals participating for four or more years have on average 3.13 fewer CLABSI per year compared to those participating for less than four years. Highmark's P4P program has shown improved outcomes with regards to CLABSI, but further research is needed to determine if QB is cost effective.

Implementing hospital pay-for-performance: Lessons learned from the French pilot program

Despite a wide implementation of pay-for-performance (P4P) programs, evidence on their impact in hospitals is still limited. Our objective was to assess the implementation of the French P4P pilot program (IFAQ1) across 222 hospitals. The study consisted of a questionnaire among four leaders in each enrolled hospital, combined with a qualitative analysis based on 33 semi-structured interviews conducted with staff in four participating hospitals. For the questionnaire results, descriptive statistics were performed and responses were analyzed by job title. For the interviews, transcripts were analysed using coding techniques. Survey results showed that leaders were mostly positive about the program and reported a good level of awareness, in contrast to the frontline staff, who remained mostly unaware of the program's existence. The main barriers were attributed to lack of clarity in program rules, and to time constraints. Different strategies were then suggested by leaders. The qualitative results added further explanations for low program adoption among hospital staff, so far. Ultimately, although paying for quality is still an intuitive approach; gaps in program awareness within enrolled hospitals may pose an important challenge to P4P efficacy. Implementation evaluations are therefore necessary for policymakers to better understand P4P adoption processes among hospitals.

Impact of Provider Incentives on Quality and Value of Health Care

The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.

Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: protocol for a grounded theory study

INTRODUCTION

There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016.

METHODS AND ANALYSIS

An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation.

ETHICS AND DISSEMINATION

The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality.

Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment

OBJECTIVE

To elicit prescribers' preferences for behavioural economics interventions designed to reduce inappropriate antibiotic prescribing, and compare these to actual behaviour.

DESIGN

Discrete choice experiment (DCE).

SETTING

47 primary care centres in Boston and Los Angeles.

PARTICIPANTS

234 primary care providers, with an average 20 years of practice.

MAIN OUTCOMES AND MEASURES

Results of a behavioural economic intervention trial were compared to prescribers' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes. In the randomised controlled trial (RCT) component, the 3 computerised prescription order entry-triggered interventions studied included: Suggested Alternatives (SA), an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed; Accountable Justifications (JA), which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient's chart; and Peer Comparison (PC), an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing. A DCE study component was administered to determine whether prescribers felt SA, JA, PC, pay-for-performance or additional clinic time would most effectively reduce their inappropriate antibiotic prescribing. Willingness-to-pay (WTP) was calculated for each intervention.

RESULTS

In the RCT, PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing, whereas SA was not significantly different from controls. In the DCE however, regardless of treatment intervention received during the RCT, prescribers overwhelmingly preferred SA, followed by PC, then JA. WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $200/month.

CONCLUSIONS

Prescribing behaviour and stated preferences are not concordant, suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions.

TRIAL REGISTRATION NUMBER

NCT01454947; Results.

Does public reporting influence antibiotic and injection prescribing to all patients? A cluster-randomized matched-pair trial in china

The inappropriate use and overuse of antibiotics and injections are serious threats to global population, and the public reporting of health care performance (PRHCP) has been an important instrument for improving the quality of care. However, existing evidence shows a mixed effect of PRHCP. This study is to explore the potential effectiveness of PRHCP that contributes to the convincing evidence of health policy and reform.This study was undertaken in Qian Jiang City, applying a matched-pair cluster-randomized trial. Twenty primary care institutions were treated as clusters and were matched into 10 pairs. Clusters in each pair were randomly assigned into a control or an intervention group. Physicians' prescribing information was publicly reported to patients and physicians monthly in the intervention group from October 2013. A total of 748,632 outpatient prescriptions were included for difference-in-difference (DID) regression model and subgroups (SGs) analysis.Overall, PRHCP intervention led to a slight reduction in the use of combined antibiotics (odds ratio [OR] = 0.870, P < 0.001) and slowed the average expenditure increase of patients (coefficient = -0.051, P < 0.001). SG analysis showed the effect of PRHCP varied among patients with different characteristics. PRHCP decreased the probability of prescriptions requiring antibiotics, combined antibiotics, and injections of patients aged 18 to 64 years old (OR < 1), and all results were statistically significant. By contrast, the results of elderly and minor patients with health insurance showed that PRHCP increased their probability of prescriptions requiring antibiotics and injections. PRHCP slowed the increase of average expenditure of most SGs.PRHCP intervention can influence the prescribing pattern of physicians. Patient factors such as age and health insurance influence the effect of PRHCP intervention, which imply that PRHCP should be designed for different patients. Patient education, aiming at radically changing attitudes toward antibiotics and injections, should be taken to promote the effectiveness of public reporting in China.

Incentives in Rheumatology: the Potential Contribution of Physician Responses to Financial Incentives, Public Reporting, and Treatment Guidelines to Health Care Sustainability

Concerns about the sustainability of current health care expenditure are focusing attention on the cost, quality and value of health care provision. Financial incentives, for example pay-for-performance (P4P), seek to reward quality and value in health care provision. There has long been an expectation that P4P schemes are coming to rheumatology. We review the available evidence about the use of incentives in this setting and provide two emerging examples of P4P schemes which may shape the future of service provision in rheumatology. Currently, there is limited and equivocal evidence in rheumatology about the impact of incentive schemes. However, reporting variation in the quality and provision of rheumatology services has highlighted examples of inefficiencies in the delivery of care. If financial incentives can improve the delivery of timely and appropriate care for rheumatology patients, then they may have an important role to play in the sustainability of health care provision.

The differential effect of compensation structures on the likelihood that firms accept new patients by insurance type

Adequate access to primary care is not universally achieved in many countries, including the United States, particularly for vulnerable populations. In this paper we use multiple years of the U.S.-based Community Tracking Survey to examine whether a variety of physician compensation structures chosen by practices influence the likelihood that the practice takes new patients from a variety of different types of insurance. Specifically, we examine the roles of customer satisfaction and quality measures on the one hand, and individual physician productivity measures on the other hand, in determining whether or not firms are more likely to accept patients who have private insurance, Medicare, or Medicaid. In the United States these different types of insurance mechanisms cover populations with different levels of vulnerability. Medicare (elderly and disabled individuals) and Medicaid (low income households) enrollees commonly have lower ability to pay any cost sharing associated with care, are more likely to have multiple comorbidities (and so be more costly to treat), and may be more sensitive to poor access. Further, these two insurers also generally reimburse less generously than private payors. Thus, if lower reimbursements interact with compensation mechanisms to discourage physician practices from accepting new patients, highly vulnerable populations may be at even greater risk than generally appreciated. We control for the potential endogeneity of incentive choice using a multi-level propensity score method. We find that the compensation incentives chosen by practices are statistically and economically significant predictors for the types of new patients that practices accept. These findings have important implications for both policy makers and private health care systems.

Participating physician preferences regarding a pay-for-performance incentive design: a discrete choice experiment

OBJECTIVE

To determine whether the magnitude of incentives or other design attributes should be prioritized and the most important attributes, according to physicians, of the diabetes P4P (pay-for-performance) program design.

DESIGN

We implemented a discrete choice experiment (DCE) to elicit the P4P incentive design-related preferences of physicians.

PARTICIPANTS

All of the physicians (n = 248) who participated in the diabetes P4P program located in the supervisory area of the northern regional branch of the Bureau of National Health Insurance in 2009 were included. The response rate was ∼ 60%.

RESULTS

Our research found that the bonus type of incentive was the most important attribute, followed by the incentive structure and the investment magnitude.

CONCLUSIONS

Physicians may feel that good P4P designs are more important than the magnitude of the investment by the insurer. The two most important P4P designs include providing the bonus type of incentive and using pay-for-excellence plus pay-for-improvement.

Public reporting influences antibiotic and injection prescription in primary care: a segmented regression analysis

RATIONALE, AIMS AND OBJECTIVES

Inappropriate use and overuse of antibiotics and injections are serious threats to the global population, particularly in developing countries. In recent decades, public reporting of health care performance (PRHCP) has been an instrument to improve the quality of care. However, existing evidence shows a mixed effect of PRHCP. This study evaluated the effect of PRHCP on physicians' prescribing practices in a sample of primary care institutions in China. Segmented regression analysis was used to produce convincing evidence for health policy and reform.

METHODS

The PRHCP intervention was implemented in Qian City that started on 1 October 2013. Performance data on prescription statistics were disclosed to patients and health workers monthly in 10 primary care institutions. A total of 326 655 valid outpatient prescriptions were collected. Monthly effective prescriptions were calculated as analytical units in the research (1st to 31st every month). This study involved multiple assessments of outcomes 13 months before and 11 months after PRHCP intervention (a total of 24 data points).

RESULTS

Segmented regression models showed downward trends from baseline on antibiotics (coefficient = -0.64, P = 0.004), combined use of antibiotics (coefficient = -0.41, P < 0.001) and injections (coefficient = -0.5957, P = 0.001) after PRHCP intervention. The average expenditure of patients slightly increased monthly before the intervention (coefficient = 0.8643, P < 0.001); PRHCP intervention also led to a temporary increase in average expenditure of patients (coefficient = 2.20, P = 0.307) but slowed down the ascending trend (coefficient = -0.45, P = 0.033). The prescription rate of antibiotics and injections after intervention (about 50%) remained high.

CONCLUSIONS

PRHCP showed positive effects on physicians' prescribing behaviour, considering the downward trends on the use of antibiotics and injections and average expenditure through the intervention. However, the effect was not immediately observed; a lag time existed before public reporting intervention worked.

Performance-related-pay in the UK public sector

Purpose

– The purpose of this paper is to provide an up-to-date, comprehensive, independent and credible assessment of relevant academic and other literature since 2007, on the effectiveness and value for money of performance-related-pay (PRP) in the public sector.

Design/methodology/approach

– PRP was studied using both economics-based literature and literature from the organisational and management field (including human resources, management sociology and psychology). An initial search of databases identified 7,401 documents regarding PRP in the public sector, which was reduced to 57 final papers included in the study (27 in the health sector, 16 in the education sector and 16 in the civil service) after abstract and full paper screening.

Findings

– The review found some evidence that PRP schemes can be effective across the three domains of the public sector for which there was evidence available (health, education and the civil service), but findings within and between the sectors are mixed, with scheme effectiveness often dependent on scheme design and organisational context.

Research limitations/implications

– The research highlights the importance of considering both economics-based and organisational literature when discussing PRP in the public sector, and the implications for motivation and PRP design.

Practical implications

– The results indicated that the design of PRP schemes could influence their effectiveness and outcomes, and the research suggests how the challenges of designing and implementing PRP schemes can be overcome in the public sector.

Social implications

– The review highlights that when implementing PRP schemes there may be gender differences in their overall effectiveness (especially in education) and there must be consideration for how fairly the PRP scheme is perceived.

Originality/value

– The paper uses literature from economics and behavioural sciences when looking at the motivational implications for PRP in the public sector.

Working under a clinic-level quality incentive: primary care clinicians' perceptions

BACKGROUND

A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level.

METHODS

This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives.

RESULTS

Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance.

CONCLUSION

The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

Sources of traffic and visitors' preferences regarding online public reports of quality: web analytics and online survey results

Background

In the context of the Affordable Care Act, there is extensive emphasis on making provider quality transparent and publicly available. Online public reports of quality exist, but little is known about how visitors find reports or about their purpose in visiting.

Objective

To address this gap, we gathered website analytics data from a national group of online public reports of hospital or physician quality and surveyed real-time visitors to those websites.

Methods

Websites were recruited from a national group of online public reports of hospital or physician quality. Analytics data were gathered from each website: number of unique visitors, method of arrival for each unique visitor, and search terms resulting in visits. Depending on the website, a survey invitation was launched for unique visitors on landing pages or on pages with quality information. Survey topics included type of respondent (eg, consumer, health care professional), purpose of visit, areas of interest, website experience, and demographics.

Results

There were 116,657 unique visitors to the 18 participating websites (1440 unique visitors/month per website), with most unique visitors arriving through search (63.95%, 74,606/116,657). Websites with a higher percent of traffic from search engines garnered more unique visitors (P=.001). The most common search terms were for individual hospitals (23.25%, 27,122/74,606) and website names (19.43%, 22,672/74,606); medical condition terms were uncommon (0.81%, 605/74,606). Survey view rate was 42.48% (49,560/116,657 invited) resulting in 1755 respondents (participation rate=3.6%). There were substantial proportions of consumer (48.43%, 850/1755) and health care professional respondents (31.39%, 551/1755). Across websites, proportions of consumer (21%-71%) and health care professional respondents (16%-48%) varied. Consumers were frequently interested in using the information to choose providers or assess the quality of their provider (52.7%, 225/427); the majority of those choosing a provider reported that they had used the information to do so (78%, 40/51). Health care professional (26.6%, 115/443) and consumer (20.8%, 92/442) respondents wanted cost information and consumers wanted patient narrative comments (31.5%, 139/442) on the public reports. Health care professional respondents rated the experience on the reports higher than consumers did (mean 7.2, SD 2.2 vs mean 6.2, SD 2.7; scale 0-10; P<.001).

Conclusions

Report sponsors interested in increasing the influence of their reports could consider using techniques to improve search engine traffic, providing cost information and patient comments, and improving the website experience for both consumers and health care professionals.

Public reporting improves antibiotic prescribing for upper respiratory tract infections in primary care: a matched-pair cluster-randomized trial in China

BACKGROUND

Inappropriate use and overuse of antibiotics is a serious concern in the treatment of upper respiratory tract infections (URTIs), especially in developing countries. In recent decades, information disclosure and public reporting (PR) has become an instrument for encouraging good practice in healthcare. This study evaluated the impact of PR on antibiotic prescribing for URTIs in a sample of primary care institutions in China.

METHODS

A matched-pair cluster-randomized trial was undertaken in QJ city, with 20 primary care institutions participating in the trial. Participating institutions were matched into pairs before being randomly assigned into a control and an intervention group. Prescription statistics were disclosed to patients, health authorities, and health workers monthly within the intervention group, starting from October 2013. Outpatient prescriptions for URTIs were collected from both groups before (1st March to 31st May, 2013) and after the intervention (1st March to 31st May, 2014). A total of 34,815 URTI prescriptions were included in a difference-in-difference analysis using multivariate linear or logistic regression models, controlling for patient attributes as well as institutional characteristics.

RESULTS

Overall, 90% URTI prescriptions required antibiotics and 21% required combined use of antibiotics. More than 77% of URTI prescriptions required intravenous (IV) injection or infusion of drugs. PR resulted in a 9 percentage point (95% CI -17 to -1) reduction in the use of oral antibiotics (adjusted RR = 39%, P = 0.027), while the use of injectable antibiotics remained unchanged. PR led to a 7 percentage point reduction (95% CI -14 to 0; adjusted RR = 36%) in combined use of antibiotics (P = 0.049), which was largely driven by a significant reduction in male patients (-7.5%, 95% CI -14 to -1, P = 0.03). The intervention had little impact on the use of IV injections or infusions, or the total prescription expenditure.

CONCLUSIONS

The results suggest that PR could improve prescribing practices in terms of reducing oral antibiotics and combined use of antibiotics; however, the impacts were limited. We suggest that PR would probably be enhanced by provider payment reform, management and training for providers, and health education for patients.

The need for a regulatory rethink: a perspective from Australia

Traditional 'hierarchical' regulation involves checks and balances and external accountability and review bodies. There have been high profile failures of this approach in England (Mid Staffs) and Australia (Bundaberg, Queensland). The regulatory framework needs to be transformed to recognise the increasing use of market and market-like mechanisms in health care. Improvement in the ability to measure quality and safety of care using routine (already collected) data facilitates this. New regulation needs to ensure quality and financial incentives are aligned. New instruments such as incorporating safety/quality measures into service descriptions, use of patient reported outcome measures, and making information about expected outcomes of care to patients available, ought to be used more widely. Improved data capture, including whether a diagnosis was present on admission, will help in improving quality and safety of care and its measurement.

Incentives and disincentives for the treatment of depression and anxiety: a scoping review

OBJECTIVE

There is widespread support for primary care to help address growing mental health care demands. Incentives and disincentives are widely used in the design of health care systems to help steer toward desired goals. The absence of a conceptual model to help understand the range of factors that influence the provision of primary mental health care inspired a scoping review of the literature. Understanding the incentives that promote and the disincentives that deter treatment for depression and anxiety in the primary care context will help to achieve goals of greater access to mental health care.

METHOD

A review of the literature was conducted to answer the question, how are incentives and disincentives conceptualized in studies investigating the treatment of common mental disorders in primary care? A comprehensive search of MEDLINE, PsycINFO, CINAHL, and Google Scholar was undertaken using Arksey and O'Malley's 5-stage methodological framework for scoping reviews.

RESULTS

We identified 27 studies. A range of incentives and disincentives influence the success of primary mental health care initiatives to treat depression and anxiety. Six types of incentives and disincentives can encourage or discourage treatment of depression and anxiety in primary care: attitudes and beliefs, training and core competencies, leadership, organizational, financial, and systemic.

CONCLUSIONS

Understanding that there are 6 different types of incentives that influence treatment for anxiety and depression in primary care may help service planners who are trying to promote improved mental health care.

Population impact of a high cardiovascular risk management program delivered by village doctors in rural China: design and rationale of a large, cluster-randomized controlled trial

Background

The high-risk strategy has been proven effective in preventing cardiovascular disease; however, the population benefits from these interventions remain unknown. This study aims to assess, at the population level, the effects of an evidence-based high cardiovascular risk management program delivered by village doctors in rural China.

Methods

The study will employ a cluster-randomized controlled trial in which a total of 120 villages in five northern provinces of China, will be assigned to either intervention (60 villages) or control (60 villages). Village doctors in intervention villages will be trained to implement a simple evidence-based management program designed to identify, treat and follow-up as many as possible individuals at high-risk of cardiovascular disease in the village. The intervention will also include performance feedback as well as a performance-based incentive payment scheme and will last for 2 years. We will draw two different (independent) random samples, before and after the intervention, 20 men aged ≥ 50 years and 20 women aged ≥60 years from each village in each sample and a total of 9,600 participants from 2 samples to measure the study outcomes at the population level. The primary outcome will be the pre-post difference in mean systolic blood pressure, analyzed with a generalized estimating equations extension of linear regression model to account for cluster effect. Secondary outcomes will include monthly clinic visits, provision of lifestyle advice, use of antihypertensive medications and use of aspirin. Process and economic evaluations will also be conducted.

Discussion

This trial will be the first implementation trial in the world to evaluate the population impact of the high-risk strategy in prevention and control of cardiovascular disease. The results are expected to provide important information (effectiveness, cost-effectiveness, feasibility and acceptability) to guide policy making for rural China as well as other resource-limited countries.

Trial registration

The trial is registered at ClinicalTrials.gov (NCT01259700). Date of initial registration is December 13, 2010.

Impact of the Iranian hospital grading system on hospitals' adherence to audited standards: an examination of possible mechanisms

INTRODUCTION

All Iranian hospitals have been subject to a grading system which determines the payments they can charge. We examined all possible pathways through which the grading system could influence hospitals' adherence to audited standards.

METHODS

Using a mixed methods study we examined five stakeholder groups: hospital staff, patients, general practitioners, health insurance organisations and surveyor organisations. Data were collected via semi-structured interviews, a questionnaire survey, observation and documentary analysis.

FINDINGS

Patients and general practitioners were generally unaware of the hospital grading. Hospital staff and insurance organisations were informed, but this was not found to influence the hospital staff's choice of where to work nor the insurance organisations contracting behaviour. The grading system was criticised for the performance standards' validity and the validity of hospitals' awarded results. Hospitals responded to financial and reputational incentives for achieving better grades, although gaming and misrepresentation was also reported.

CONCLUSION

Pay-for-performance was the main influential factor in shaping hospitals' adherence to audit standards. Other potential mechanisms for influencing hospital behaviour, the selection mechanism and intrinsic motives, were not found to be sufficient to affect hospital behaviour.

Link between pay for performance incentives and physician payment mechanisms: evidence from the diabetes management incentive in Ontario

Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as a salary, fee-for-services and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this article, we study this link using the recent primary care physician payment reform in Ontario as a natural experiment and the Diabetes Management Incentive as a case study. Using a comprehensive administrative data strategy and a difference-in-differences matching strategy, we find that physicians in a blended capitation model are more responsive to the Diabetes Management Incentive than physicians in an enhanced fee-for-service model. We show that this result implies that the optimal size of P4P incentives vary negatively with the degree of supply-side cost-sharing. These results have important implications for the design of P4P programs and the cost of their implementation.

Reward-based, task-setting education strategy on glycemic control and self-management for low-income outpatients with type 2 diabetes

AIMS/INTRODUCTION

The purpose of the study was to determine the feasibility and effect of a reward-based, task-setting strategy for low-income outpatients with type 2 diabetes.

MATERIALS AND METHODS

Indigent diabetes outpatients without glucometers were eligible to participate in this trial. A total of 132 cases were randomly recruited. Participants in group B used glucometers for self-monitoring at no cost. Group A participants could keep the glucometers only if the glycosylated hemoglobin level declined compared with the baseline visit; for those not achieving a reduction in the glycosylated hemoglobin level, the glucometers would have to be returned. Group C served as the control group without self-monitoring setout. Diabetes education was provided to all groups. Metabolic indices and self-management were evaluated after 6 months of follow up.

RESULTS

Group A had a significant decline in the glycosylated hemoglobin level (-0.97%) and medical costs (-159 yuan) compared with the baseline visit, whereas groups B and C had a decrease in the glycosylated hemoglobin levels alone (-0.62 and -0.57%, respectively). The body mass index did not change significantly in any group. There was a statistical difference in the glycosylated hemoglobin level of group A compared with groups B and C. Self-management in group A improved the outcome relative to groups B and C.

CONCLUSIONS

This preliminary evidence suggests that the program is feasible, acceptable for improving patient self-management, and cost-effective in reducing the glycosylated hemoglobin level and medical costs.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial

IMPORTANCE

Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied.

OBJECTIVE

To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance.

INTERVENTIONS

Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to both the intervention and control groups.

MAIN OUTCOMES AND MEASURES

Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention.

RESULTS

Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant.

CONCLUSIONS AND RELEVANCE

Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00884013.

Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial

IMPORTANCE

Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.

OBJECTIVE

To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).

INTERVENTIONS

Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.

MAIN OUTCOMES AND MEASURES

Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.

RESULTS

Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.

CONCLUSIONS AND RELEVANCE

Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00302718.

Paying physician group practices for quality: A statewide quasi-experiment

This article presents the results of a unique quasi-experiment of the effects of a large-scale pay-for-performance (P4P) program implemented by a leading health insurer in Washington state during 2001-2007. The authors received external funding to provide an objective impact evaluation of the program. The program was unique in several respects: (1) It was designed dynamically, with two discrete intervention periods-one in which payment incentives were based on relative performance (the "contest" period) and a second in which payment incentives were based on absolute performance compared to achievable benchmarks. (2) The program was designed in collaboration with large multispecialty group practices, with an explicit run-in period to test the quality metrics. Public reporting of the quality scorecard for all participating medical groups was introduced 1 year before the quality incentive payment program's inception, and continued throughout 2002-2007. (3) The program was implemented in stages with distinct medical groups. A control group of comparable group practices also was assembled, and difference-in-differences methodology was applied to estimate program effects. Case mix measures were included in all multivariate analyses. The regression design permitted a contrast of intervention effects between the "contest" approach in the sub-period of 2003-2004 and the absolute standard, "achievable benchmarks of care" approach in sub-period 2005-2007. Most of the statistically significant quality incentive program coefficients were small and negative (opposite to program intent). A consistent pattern of differential intervention impact in the sub-periods did not emerge. Cumulatively, the probit regression estimates indicate that neither the quality scorecard nor the quality incentive payment program had a significant positive effect on general clinical quality. Based on key informant interviews with medical leaders, practicing physicians, and administrators of the participating groups, the authors conclude that several factors likely combined to dampen program effects: (1) modest size of the incentive; (2) use of rewards only, rather than a balance of rewards and penalties; (3) targeting incentive payments to the group, thus potentially weakening incentive effects at the individual level.

Assessment of a pay-for-performance program in primary care designed by target users

BACKGROUND

Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects.

OBJECTIVE

To assess changes in performance after introducing a participatory P4P program.

DESIGN

An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark.

MAIN OUTCOME MEASURES

Quality indicators for clinical care (process and outcome) and patient experience.

RESULTS

We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement.

CONCLUSIONS

A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

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.

Design choices made by target users for a pay-for-performance program in primary care: an action research approach

Background

International interest in pay-for-performance (P4P) initiatives to improve quality of health care is growing. Current programs vary in the methods of performance measurement, appraisal and reimbursement. One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs. We developed a P4P program in which the target users were involved in decisions about the P4P methods.

Methods

For the development of the P4P program a framework was used which distinguished three main components: performance measurement, appraisal and reimbursement. Based on this framework design choices were discussed in two panels of target users using an adapted Delphi procedure. The target users were 65 general practices and two health insurance companies in the South of the Netherlands.

Results

Performance measurement was linked to the Dutch accreditation program based on three domains (clinical care, practice management and patient experience). The general practice was chosen as unit of assessment. Relative standards were set at the 25^th percentile of group performance. The incentive for clinical care was set twice as high as the one for practice management and patient experience. Quality scores were to be calculated separately for all three domains, and for both the quality level and the improvement of performance. The incentive for quality level was set thrice as high as the one for the improvement of performance. For reimbursement, quality scores were divided into seven levels. A practice with a quality score in the lowest group was not supposed to receive a bonus. The additional payment grew proportionally for each extra group. The bonus aimed at was on average 5% to 10% of the practice income.

Conclusions

Designing a P4P program for primary care with involvement of the target users gave us an insight into their motives, which can help others who need to discuss similar programs. The resulting program is in line with target users' views and assessments of relevance and applicability. This may enhance their commitment to the program as was indicated by the growing number of voluntary participants after a successfully performed field test during the procedure. The elements of our framework can be very helpful for others who are developing or evaluating a P4P program.

Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms

PURPOSE

To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.

DESIGN/METHODOLOGY/APPROACH

Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants' success and effects on patient care.

FINDINGS

Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.

LIMITATIONS

This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes.

PRACTICAL IMPLICATIONS

Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support.

ORIGINALITY/VALUE

We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol

Background

Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens.

Methods/design

This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period.

Discussion

We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements.

Trial Registration

http://www.clinicaltrials.govNCT00302718

A health insurance company-initiated practice support intervention for optimizing acid-suppressing drug prescriptions in primary care

BACKGROUND

A health insurance-initiated programme to improve cost-effectiveness of acid-suppressing drugs (ASDs).

AIM

To evaluate the effect of two different interventions of general practitioner support in reducing drug prescription.

MATERIALS AND METHODS

A sequential cluster randomized controlled trial with 90 participating general practitioners in a telephone support (TS) group or practice visit (PV) group. TS group received support in phase-1 (first 6 months), but served as control group in phase-2 (6-12 months period). PV group received no intervention in phase-1, serving as the control group for the TS group, but received support in phase-2. Prescription data were extracted from Agis Health Insurance Database. Outcomes were the proportion of responders to drug reduction and the number of defined daily dose (DDD). Differences in users and DDD were analysed using multilevel regression analysis.

RESULTS

At baseline, 3424 patients used ASD chronically (211 DDDs, on average). The difference between TS and control groups among responders was 3.2% [95% confidence interval (CI): 0.8; 5.6] and relative risk was 1.26 (95% CI: 1.06; 1.51). The difference between PV and control groups was not relevant (0.4%, 95% CI: -1.99; 2.79 and relative risk: 1.01, 95% CI: 0.82; 1.20). The difference in DDD per patient was -3.0 (95% CI: -8.9; 2.9) and -5.82 (95% CI: -12.4; 0.73), respectively.

CONCLUSION

This health insurance company-initiated intervention had a moderate effect on ASD prescription. In contrast to TS, PVs did not seem to reduce ASD prescription rates.

An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes

BACKGROUND

There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes.

OBJECTIVES

To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes.

METHODS

We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting.

MAIN RESULTS

We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review).

AUTHORS' CONCLUSIONS

Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.

[Pay for performance (P4P). Long-term effects and perspectives]

After 10 years of experience and research, a wide array of results on evaluation and long-term effects of pay for performance (P4P) programs have been published. These data do not only give insight into most of the problems of implementation, but also into aspects which, in part, may attenuate the high expectations at the beginning of the discussion. P4P programs exhibit a ceiling effect, some improvements are reversed after incentives are cancelled, and improvements show opportunity costs as absent improvements for indicators, which are not object to financial incentives (in some cases for the same disease). These observations can be explained by the hypothesis that P4P programs have characteristics of fee-for-service reimbursement, if symmetric information is available for insurance and provider. P4P programs are local instruments. While integration of healthcare is considered as an important issue, they should be combined with programs and incentives which foster further vertical and horizontal integration. For Germany, further research in the implementation and effects of P4P programs is necessary.

[The life cycle of general practitioners' professional motivations: the case of prevention]

BACKGROUND

The analysis of "professional motivations", mainly through the possible crowding-out effects between extrinsic and intrinsic motivations, has become an issue of great concern in the economic literature. This paper aims at applying this topic to the healthcare professions where the proper scaling up of pay-for-performance (P4P) policies by public authorities is at stake.

METHODS

We used a panel of 528 self-employed general practitioners in the "Provence-Alpes-Côte d'Azur" region in France to provide an interpersonal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. Then, we applied a Tobit model in order to specify the main explicative variables of the share of intrinsic motivations entering into physicians' total motivations.

RESULTS

The relative share of intrinsic motivations was quite high among physicians paid with fixed fees. We found a significant effect of age on intrinsic motivations describing a U-shaped curve which can be interpreted as being the result of a "life cycle of medical motivations" or a generational effect.

CONCLUSION

The cross-sectional nature of the data does not allow us to draw any conclusions concerning the predominance of the generational effect or the "life cycle effect" on the evolution of the relative share of physician's intrinsic motivations. Nevertheless, the U-shaped relation between intrinsic motivations and age questions the suitability of using uniformly P4P mechanisms. The generations or age groups of self-employed physicians who seem to be less responsive to extrinsic motivations are more likely to favour the introduction of other types of payment schemes (capitation or salary systems) or regulation tools such as clinical practice guidelines.

An alternative to pay-for-performance: one health plan's approach to quality improvement

To address concerns about the quality of care, health plans have used varying approaches to support quality improvement (QI). Pay-for-performance (P4P) is the most commonly used and discussed approach. P4P programs have many challenges in design and execution, particularly for Medicaid providers. In order to find an alternative to P4P, CareOregon--a nonprofit health plan serving Medicaid and Medicare enrollees--developed the Care Support and System Innovation (CSSI) Program. An evaluation was conducted to assess the overall affect of the CSSI Program in promoting comprehensive improvements in quality of care and the extent to which it has the potential to offer a viable alternative to P4P. The evaluation found that the CSSI Program successfully addressed many challenges inherent in P4P. The CSSI Program engaged providers, fostered a culture of QI within CareOregon's network, and provided practices with the opportunity to develop sustainable and innovative solutions to address quality concerns. Success of the program was attributed to CareOregon's focus on building relationships while providing technical assistance and responsive funding. While health outcome data were not available to assess impact on CareOregon's members, evaluation findings highlight the importance of collaboration in QI efforts, and suggest that the model has the potential to overcome many of the challenges faced by P4P.

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.