What can the past of pay-for-performance tell us about the future of Value-Based Purchasing in Medicare?

Longitudinal participation in delivery and payment reform programs among US Primary Care Organizations

OBJECTIVE

To assess longitudinal primary care organization participation patterns in large-scale reform programs and identify organizational characteristics associated with multiprogram participation.

DATA SOURCES

Secondary data analysis of national program participation data over an eight-year period (2009-2016).

STUDY DESIGN

We conducted a retrospective, observational study by creating a unique set of data linkages (including Medicare and Medicaid Meaningful Use and Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) participation from CMS, Patient-Centered Medical Home (PCMH) participation from the National Committee for Quality Assurance, and organizational characteristics) to measure longitudinal participation and identify what types of organizations participate in one or more of these reform programs. We used multivariate models to identify organizational characteristics that differentiate those that participate in none, one, or two-to-three programs.

DATA EXTRACTION METHODS

We used Medicare claims to identify organizations that delivered primary care services (n = 56 ,287) and then linked organizations to program participation data and characteristics.

PRINCIPAL FINDINGS

No program achieved more than 50% participation across the 56,287 organizations in a given year, and participation levels flattened or decreased in later years. 36% of organizations did not participate in any program over the eight-year study period; 50% participated in one; 13% in two; and 1% in all three. 14.31% of organizations participated in five or more years of Meaningful Use while 3.84% of organizations participated in five years of the MSSP ACO Program and 0.64% participated in at least five years of PCMH. Larger organizations, those with younger providers, those with more primary care providers, and those with larger Medicare patient panels were more likely to participate in more programs.

CONCLUSIONS AND RELEVANCE

Primary care transformation via use of voluntary programs, each with their own participation requirements and approach to incentives, has failed to broadly engage primary care organizations. Those that have chosen to participate in multiple programs are likely those already providing high-quality care.

Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

Incentive-based pay-for-performance (P4P) models have been introduced during the last 2 decades as a mechanism to improve the delivery of evidence-based care that ensures clinical quality and improves health outcomes. There is mixed evidence that P4P has a positive effect on health outcomes and researchers cite lack of engagement from health care professionals as a limiting factor. This qualitative metasynthesis of existing qualitative research was conducted to integrate health care professionals’ perceptions of P4P in clinical practice. Four themes emerged during the research process: positive perceptions of the value of performance measurement and associated financial incentives; negative perceptions of the performance measurement and associated financial incentives; perceptions of how P4P programs influence the quality/appropriateness of care; and perceptions of the influence of P4P program on professional roles and workplace dynamics. Identifying factors that influence health care professionals’ perceptions about this type of value-based payment model will guide future research.

Real-time Feedback in Pay-for-Performance: Does More Information Lead to Improvement?

BACKGROUND

Pay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood.

OBJECTIVE

To determine whether an increase in information feedback without changes to financial incentives resulted in improved physician performance within an existing P4P program.

INTERVENTION/EXPOSURE

Implementation of a new registry enabling real-time feedback to physicians on quality measure performance.

DESIGN

Observational, predictive piecewise model at the physician-measure level to examine whether registry introduction associated with performance changes. We used detailed physician quality measure data 3 years prior to registry implementation (2010-2012) and 2 years after implementation (2014-2015). We also linked physician-level data including age, gender, and board certification; group-level data including registry click rates; and patient panel data including chronic conditions.

PARTICIPANTS

Four hundred thirty-four physicians continuously affiliated with Advocate from 2010 to 2015.

MAIN MEASURES

Physician performance on ten quality metrics.

KEY RESULTS

We found no consistent pattern of improvement associated with the availability of real-time information across ten measures. Relative to predicted performance without the registry, average performance increased for two measures (childhood immunization status-rotavirus (p < 0.001) and diabetes care-medical attention for nephropathy (p = 0.024)) and decreased for three measures (childhood immunization status-influenza (p < 0.001) and diabetes care-HbA1c testing (p < 0.001) and poor HbA1c control (p < 0.001)). Results were consistent for subgroup analysis on those most able to improve, i.e., physicians in the bottom tertile of performance prior to registry introduction. Physicians who improved most were in groups that accessed the registry more than those who improved least (8.0 vs 10.0 times per week, p = 0.010).

CONCLUSIONS

More frequent provision of information, provided in real-time, was insufficient to improve physician performance in an existing P4P program with high baseline performance. Results suggest that electronic registries may not themselves drive performance improvement. Future work should consider testing information feedback enhancements with financial incentives.

Changes in Hospital Quality Associated with Hospital Value-Based Purchasing

BACKGROUND

Starting in fiscal year 2013, the Hospital Value-Based Purchasing (HVBP) program introduced quality performance-based adjustments of up to 1% to Medicare reimbursements for acute care hospitals.

METHODS

We evaluated whether quality improved more in acute care hospitals that were exposed to HVBP than in control hospitals (Critical Access Hospitals, which were not exposed to HVBP). The measures of quality were composite measures of clinical process and patient experience (measured in units of standard deviations, with a value of 1 indicating performance that was 1 standard deviation [SD] above the hospital mean) and 30-day risk-standardized mortality among patients who were admitted to the hospital for acute myocardial infarction, heart failure, or pneumonia. The changes in quality measures after the introduction of HVBP were assessed for matched samples of acute care hospitals (the number of hospitals included in the analyses ranged from 1364 for mortality among patients admitted for acute myocardial infarction to 2615 for mortality among patients admitted for pneumonia) and control hospitals (number of hospitals ranged from 31 to 617). Matching was based on preintervention performance with regard to the quality measures. We evaluated performance over the first 4 years of HVBP.

RESULTS

Improvements in clinical-process and patient-experience measures were not significantly greater among hospitals exposed to HVBP than among control hospitals, with difference-in-differences estimates of 0.079 SD (95% confidence interval [CI], -0.140 to 0.299) for clinical process and -0.092 SD (95% CI, -0.307 to 0.122) for patient experience. HVBP was not associated with significant reductions in mortality among patients who were admitted for acute myocardial infarction (difference-in-differences estimate, -0.282 percentage points [95% CI, -1.715 to 1.152]) or heart failure (-0.212 percentage points [95% CI, -0.532 to 0.108]), but it was associated with a significant reduction in mortality among patients who were admitted for pneumonia (-0.431 percentage points [95% CI, -0.714 to -0.148]).

CONCLUSIONS

In our study, HVBP was not associated with improvements in measures of clinical process or patient experience and was not associated with significant reductions in two of three mortality measures. (Funded by the National Institute on Aging.).

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.

Effectiveness of Pay-for-Performance Incentive Designs on Diabetes Care

BACKGROUND

Taiwan's National Health Insurance program implemented a pay-for-performance (P4P) program based on process measures in 2001. In late 2006, the P4P was revised to also include achievement of outcome measures.

OBJECTIVES

This study examined whether a change in P4P incentive design structure affected diabetes outcomes.

RESEARCH DESIGN AND METHOD

We used a longitudinal cohort study design using 2 population-based databases. Newly enrolled P4P patients with diabetes in 2002-2003 (phase 1) and 2007-2008 (phase 2) made up the study cohorts. Propensity score matching was used to match comparable cohorts in each phase. In total, 46,286 matched cohorts in phase 1 and 2 were analyzed. Process measures were defined as the provision of tests of glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and blood pressure, and outcome measures as changes in those values between baseline and last follow-up within 3 years. Patient-level generalized linear regression models were used and patient characteristics, physician characteristics, and health care facility characteristics were adjusted for.

RESULTS

Our results indicated that the process measures of HbA1c and low-density lipoprotein cholesterol tests did not differ significantly between the 2 phases. In addition, better improvements were noted in outcome measures for the phase 2 patients (ie, HbA1c level and lipid profiles), whereas nonincentivized intermediate measures (eg, blood pressure) showed no negative unintended consequences.

CONCLUSIONS

Quality of care tended to be better when both process and targeted outcome measures were combined as quality metrics in the P4P program in Taiwan.

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.

Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study

BACKGROUND

Introduced in 2004, the UK's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We tested whether the QOF was associated with reduced population mortality.

METHODS

We used population-level mortality statistics between 1994 and 2010 for the UK and other high-income countries that were not exposed to pay-for-performance. The primary outcome was age-adjusted and sex-adjusted mortality per 100,000 people for a composite outcome of chronic disorders that were targeted by the QOF. Secondary outcomes were age-adjusted and sex-adjusted mortality for ischaemic heart disease, cancer, and a composite of all non-targeted conditions. For each study outcome, we created a so-called synthetic UK as a weighted combination of comparison countries. We then estimated difference-in-differences models to test whether mortality fell more in the UK than in the synthetic UK after the QOF.

FINDINGS

Introduction of the QOF was not significantly associated with changes in population mortality for the composite outcome (-3.68 per 100,000 population [95% CI -8.16 to 0.80]; p=0.107), ischaemic heart disease (-2.21 per 100,000 [-6.86 to 2.44]; p=0.357), cancer (0.28 per 100,000 [-0.99 to 1.55]; p=0.679), or all non-targeted conditions (11.60 per 100,000 [-3.91 to 27.11]; p=0.143).

INTERPRETATION

Although we noted small mortality reductions for a composite outcome of targeted disorders, the QOF was not associated with significant changes in mortality. Our findings have implications for the probable effects of similar programmes on population health outcomes. The relation between incentives and mortality needs to be assessed in specific disease domains.

FUNDING

None.

Linking Spending and Quality Indicators to Measure Value and Efficiency in Health Care

Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care.

Effects of Changes in Diabetes Pay-for-Performance Incentive Designs on Patient Risk Selection

OBJECTIVE

Taiwan's National Health Insurance (NHI) Program implemented a Diabetes Pay-for-Performance Program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was reformed to also include achievement of intermediate health outcomes. This study examined how the change in design affected patient risk selection.

DESIGNS/STUDY POPULATIONS

Study populations were identified from a 2002 to 2003 period (Phase 1) and a 2007 to 2008 period (Phase 2), spanning pre- and postimplementation of reforms in the P4P incentive design. Phase 1 had 74,529 newly enrolled P4P patients and 215,572 non-P4P patients, and Phase 2 had 76,901 newly enrolled P4P patients and 299,573 non-P4P patients. Logistic regression models were used to estimate the effect of changes in design on P4P patient selection.

PRINCIPAL FINDINGS

Patients with greater disease severity and comorbidity were more likely to be excluded from the P4P program in both phases. Furthermore, the additional financial incentive for patients' intermediate outcomes moderately worsened patient risk selection.

CONCLUSIONS

Policy makers need to carefully monitor the care of the diabetes patients with more severe and complex disease statuses after the changes of P4P financial incentive design.

Physician practice participation in accountable care organizations: the emergence of the unicorn

OBJECTIVE

To provide the first nationally based information on physician practice involvement in ACOs.

DATA SOURCES/STUDY SETTING

Primary data from the third National Survey of Physician Organizations (January 2012-May 2013).

STUDY DESIGN

We conducted a 40-minute phone survey in a sample of physician practices. A nationally representative sample of practices was surveyed in order to provide estimates of organizational characteristics, care management processes, ACO participation, and related variables for four major chronic illnesses.

DATA COLLECTION/EXTRACTION METHODS

We evaluated the associations between ACO participation, organizational characteristics, and a 25-point index of patient-centered medical home processes.

PRINCIPAL FINDINGS

We found that 23.7 percent of physician practices (n = 280) reported joining an ACO; 15.7 percent (n = 186) were planning to become involved within the next 12 months and 60.6 percent (n = 717) reported no involvement and no plans to become involved. Larger practices, those receiving patients from an IPA and/or PHO, those that were physician-owned versus hospital/health system-owned, those located in New England, and those with greater patient-centered medical home (PCMH) care management processes were more likely to have joined an ACO.

CONCLUSIONS

Physician practices that are currently participating in ACOs appear to be relatively large, or to be members of an IPA or PHO, are less likely to be hospital-owned and are more likely to use more care management processes than nonparticipating practices.

Innovative Payment Mechanisms in Maryland Hospitals: An Empirical Analysis of Readmissions under Total Patient Revenue

BACKGROUND

The state of Maryland implemented innovative budgeting of outpatient and inpatient services in eight rural hospitals under the Total Patient Revenue (TPR) system in July, 2010.

METHODS

This paper uses data on Maryland discharges from the 2009-2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Individual inpatient discharges from eight treatment hospitals and three rural control hospitals (n=374,353) are analyzed. To get robust estimates and control for trends in the state, we also compare treatment hospitals to all hospitals in Maryland that report readmissions (n=1,997,164). Linear probability models using the difference-in-differences approach with hospital fixed effects are estimated to determine the effect of the innovative payment mechanisms on hospital readmissions, controlling for patient demographics and characteristics.

RESULTS

Difference-in-differences estimates show that after implementation of TPR in the treatment hospitals, there were no statistically significant changes in the predicted probability of readmissions.

CONCLUSIONS

Early evidence from the TPR program shows that readmissions were not affected in the 18 months after implementation.

IMPLICATIONS

: As the health care system innovates, it is important to evaluate the success of these innovations. One of the goals of TPR was to lower readmission rates, however these rates did not show consistent downward trends after implementation. Our results suggest that payment innovations that provide financial incentives to ensure patients receive care in the most appropriate setting while maintaining quality of care may not have immediate effects on commonly used measures of hospital quality, particularly for rural hospitals that may lack coordinated care delivery infrastructure.