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Aronoff-Spencer E, Asgari P, Finlayson TL, Gavin J, Forstey M, Norman GJ, Pierce I, Ochoa C, Downey P, Becerra K, Agha Z. A comprehensive assessment for community-based, person-centered care for older adults. BMC Geriatr 2020; 20:193. [PMID: 32503440 PMCID: PMC7275322 DOI: 10.1186/s12877-020-1502-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/03/2020] [Indexed: 11/25/2022] Open
Abstract
Background Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center. Methods A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016–2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency. Results The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL. Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55–2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09–3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12–2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04–2.10]). Conclusion Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.
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Affiliation(s)
| | - Padideh Asgari
- Gary and Mary West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA, 92037, USA
| | - Tracy L Finlayson
- San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182-4162, USA.
| | - Joseph Gavin
- Serving Seniors, 1525 Fourth Avenue, San Diego, CA, 92101, USA
| | - Melinda Forstey
- Gary and Mary West Senior Dental Center, 1525 Fourth Avenue - second floor, San Diego, CA, 92101, USA
| | - Gregory J Norman
- Gary and Mary West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA, 92037, USA
| | - Ian Pierce
- Gary and Mary West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA, 92037, USA
| | - Carlos Ochoa
- Serving Seniors, 1525 Fourth Avenue, San Diego, CA, 92101, USA
| | - Paul Downey
- Serving Seniors, 1525 Fourth Avenue, San Diego, CA, 92101, USA
| | - Karen Becerra
- Gary and Mary West Senior Dental Center, 1525 Fourth Avenue - second floor, San Diego, CA, 92101, USA
| | - Zia Agha
- Gary and Mary West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA, 92037, USA
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van den Brand FA, Nagelhout GE, Reda AA, Winkens B, Evers SMAA, Kotz D, van Schayck OCP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database Syst Rev 2017; 9:CD004305. [PMID: 28898403 PMCID: PMC6483741 DOI: 10.1002/14651858.cd004305.pub5] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review. OBJECTIVES The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016. SELECTION CRITERIA We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model. MAIN RESULTS In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study. AUTHORS' CONCLUSIONS Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.
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Affiliation(s)
- Floor A van den Brand
- Maastricht University (CAPHRI)Department of Family MedicineP.debyeplein 1MaastrichtZuid‐LimburgNetherlands6229 HA
| | - Gera E Nagelhout
- Maastricht University (CAPHRI)Department of Family MedicineP.debyeplein 1MaastrichtZuid‐LimburgNetherlands6229 HA
- IVO Addiction Research InstituteRotterdamNetherlands
- Maastricht University (CAPHRI)Department of Health PromotionMaastrichtNetherlands
| | - Ayalu A Reda
- Brown UniversityDepartment of Biostatistics, School of Public HealthProvidenceRIUSA
- Brown UniversityDepartment of SociologyProvidenceUSA
- Brown UniversityPopulation Studies and Training CentreProvidenceUSA
| | - Bjorn Winkens
- Maastricht UniversityDepartment of Methodology and Statistics, Faculty of Health Medicine and Life Sciences (FHML)Debyeplein 1MaastrichtNetherlands6200 MD
| | - Silvia M A A Evers
- Maastricht University (CAPHRI)Department of Health Services ResearchPO Box 6166200 MDMaastrichtNetherlands6229 ER
| | - Daniel Kotz
- Maastricht University (CAPHRI)Department of Family MedicineP.debyeplein 1MaastrichtZuid‐LimburgNetherlands6229 HA
- Heinrich‐Heine‐UniversityInstitute of General Practice, Addiction Research and Clinical Epidemiology, Medical FacultyDüsseldorfGermany
| | - Onno CP van Schayck
- Maastricht University (CAPHRI)Department of Family MedicineP.debyeplein 1MaastrichtZuid‐LimburgNetherlands6229 HA
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Maciosek MV, LaFrance AB, Dehmer SP, McGree DA, Xu Z, Flottemesch TJ, Solberg LI. Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults. Ann Fam Med 2017; 15:37-47. [PMID: 28376459 PMCID: PMC5217842 DOI: 10.1370/afm.2022] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/31/2016] [Accepted: 11/18/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation. METHODS We conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews. RESULTS Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates. CONCLUSIONS Brief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.
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Affiliation(s)
| | | | | | | | - Zack Xu
- HealthPartners Institute, Minneapolis, Minnesota
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Young GJ, White B, Burgess JF, Berlowitz D, Meterko M, Guldin MR, Bokhour BG. Conceptual Issues in the Design and Implementation of Pay-for-Quality Programs. Am J Med Qual 2016; 20:144-50. [PMID: 15951520 DOI: 10.1177/1062860605275222] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article identifies and discusses key conceptual issues in designing and implementing pay-for-quality programs. Such programs offer financial incentives to providers for achieving predefined quality targets. The purpose of the article is to provide health care professionals with a framework for designing, implementing, and evaluating pay-for-quality programs. Examples are drawn from the Rewarding Results demonstration project for which the authors serve as the national evaluation team.
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Affiliation(s)
- Gary J Young
- Center for Organization, Leadership and Management Research, Department of Veterans Affairs, USA.
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Ramsay PP, Shortell SM, Casalino LP, Rodriguez HP, Rittenhouse DR. A Longitudinal Study of Medical Practices' Treatment of Patients Who Use Tobacco. Am J Prev Med 2016; 50:328-335. [PMID: 26365836 DOI: 10.1016/j.amepre.2015.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/18/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many patients who use tobacco have never been encouraged by their healthcare providers to quit. In recent years, incentives have been provided for medical practices to incorporate tobacco-cessation processes into routine care. This study examined growth in use of these processes as well as organizational and policy factors associated with their implementation. METHODS Data from three National Study of Physician Organizations surveys fielded in 2006-2013 were analyzed in 2014. The analyses estimated multivariate longitudinal and cross-sectional linear regression models to assess the relationship between implementation of cessation processes and change in practices' characteristics and external incentives, including state mandates for tobacco-cessation coverage. RESULTS Systematic identification of patients who use tobacco increased in large (26% to 91%, p<0.0001) and small-medium practices (69% to 83%, p<0.0001). Neither routine advice to quit nor referral to counseling and guideline-based point-of-care reminders increased. Practice feedback to physicians on their use of cessation interventions increased (18% to 29%, p<0.0001) for small-medium practices. State-mandated coverage was associated with the use of cessation processes in small-medium practices (p<0.0001), as was pay for performance participation (p<0.0001); public reporting (p<0.0001); Medicaid revenue (p=0.02); and practice size (p<0.0001). Among large practices, predictors were practice size (p<0.0001); hospital ownership (p=0.004); public reporting (p=0.03); and primary care practice (p=0.04). CONCLUSIONS The findings suggest that state-mandated coverage for tobacco-cessation treatment and increased use of external incentives such as pay for performance and public reporting programs may improve care for patients who use tobacco.
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Affiliation(s)
- Patricia P Ramsay
- School of Public Health, University of California Berkeley, Berkeley, California.
| | - Stephen M Shortell
- School of Public Health, University of California Berkeley, Berkeley, California
| | - Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Hector P Rodriguez
- School of Public Health, University of California Berkeley, Berkeley, California
| | - Diane R Rittenhouse
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
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Bridging the Gap between Evidence and Practice for Adults with Medically Refractory Temporal Lobe Epilepsy: Is a Change in Funding Policy Needed to Stimulate a Shift in Practice? EPILEPSY RESEARCH AND TREATMENT 2015; 2015:675071. [PMID: 26770822 PMCID: PMC4685103 DOI: 10.1155/2015/675071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 11/11/2015] [Indexed: 11/30/2022]
Abstract
Objective. Surgery for medically refractory epilepsy (MRE) in adults has been shown to be effective but underutilized. Comprehensive health economic evaluations of surgery compared with continued medical management are limited. Policy changes may be necessary to influence practice shift. Methods. A critical review of the literature on health economic analyses for adults with MRE was conducted. The MEDLINE, EMBASE, CENTRAL, CRD, and EconLit databases were searched using relevant subject headings and keywords pertaining to adults, epilepsy, and health economic evaluations. The screening was conducted independently and in duplicate. Results. Four studies were identified (1 Canadian, 2 American, and 1 French). Two were cost-utility analyses and 2 were cost-effectiveness evaluations. Only one was conducted after the effectiveness of surgery was established through a randomized trial. All suggested surgery to be favorable in the medium to long term (7-8 years and beyond). The reduction of medication use was the major cost-saving parameter in favor of surgery. Conclusions. Although updated evaluations that are more generalizable across settings are necessary, surgery appears to be a favorable option from a health economic perspective. Given the limited success of knowledge translation endeavours, funder-level policy changes such as quality-based purchasing may be necessary to induce a shift in practice.
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Kirschner K, Braspenning J, Akkermans RP, Jacobs JEA, Grol R. Assessment of a pay-for-performance program in primary care designed by target users. Fam Pract 2013; 30:161-71. [PMID: 22997223 DOI: 10.1093/fampra/cms055] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Kirsten Kirschner
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
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Emmert M, Eijkenaar F, Kemter H, Esslinger AS, Schöffski O. Economic evaluation of pay-for-performance in health care: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2012; 13:755-767. [PMID: 21660562 DOI: 10.1007/s10198-011-0329-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 05/25/2011] [Indexed: 05/28/2023]
Abstract
BACKGROUND Pay-for-performance (P4P) intents to stimulate both more effective and more efficient health care delivery. To date, evidence on whether P4P itself is an efficient method has not been systematically analyzed. OBJECTIVE To identify and analyze the existing literature regarding economic evaluation of P4P. DATA SOURCES English, German, Spanish, and Turkish language literature were searched in the following databases: Business Source Complete, the Cochrane Library, Econlit, ISI web of knowledge, Medline (via PubMed), and PsycInfo (January 2000-April 2010). STUDY SELECTION Articles published in peer-reviewed journals and describing economic evaluations of P4P initiatives. Full economic evaluations, considering costs and consequences of the P4P intervention simultaneously, were the prime focus. Additionally, comparative partial evaluations were included if costs were described and the study allows for an assessment of consequences. Both experimental and observational studies were considered. RESULTS In total, nine studies could be identified. Three studies could be regarded as full economic evaluations, and six studies were classified as partial economic evaluations. Based on the full economic evaluations, P4P efficiency could not be demonstrated. Partial economic evaluations showed mixed results, but several flaws limit their significance. Ranges of costs and consequences were typically narrow, and programs differed considerably in design. Methodological quality assessment showed scores between 32% and 65%. CONCLUSION The results show that evidence on the efficiency of P4P is scarce and inconclusive. P4P efficiency could not be demonstrated. The small number and variability of included studies limit the strength of our conclusions. More research addressing P4P efficiency is needed.
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Affiliation(s)
- Martin Emmert
- Institute of Management (IFM), School of Business and Economics, Friedrich-Alexander-University Erlangen-Nuremberg, Lange Gasse 20, 90403, Nuremberg, Germany.
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Baek JD, Xirasagar S, Stoskopf CH, Seidman RL. Physician-targeted financial incentives and primary care physicians' self-reported ability to provide high-quality primary care. J Prim Care Community Health 2012; 4:182-8. [PMID: 23799705 DOI: 10.1177/2150131912462036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE High-quality primary care is envisaged as the centerpiece of the emerging health care delivery system under the Affordable Care Act. Reengineering the US health care system into a primary care-driven model will require widespread, rapid changes in the management and organization of primary care physicians (PCPs). Financial incentives to influence physician behavior have been attempted with various approaches, without empirical evidence of their effectiveness in improving care quality. This study examines the above research question adjusting for the patient-centeredness of the practice climate, a major contextual factor affecting PCPs' ability to provide high-quality care. METHODS Secondary data on a sample of salaried PCPs (n = 1733) from the nation-wide Community Tracking Study Physician Survey 2004-2005 were subject to generalized multinomial logit modeling to examine associations between financial incentives and PCPs' self-reported ability to provide quality care. RESULTS After adjusting for patient-centered medical home (PCMH)-consistent practice environment, financial incentive aligned with care quality/care content is positively associated with PCPs' ability to provide high-quality care. An encouraging finding was that financial incentives aligned with clinic productivity/profitability do not to impede high-quality care in a PCMH practice environment. CONCLUSION Financial incentives targeted to care quality or content indicators may facilitate rapid transformation of the health system to a primary care-driven system. The study provides empirical evidence of the utility of practically deployable financial incentives to facilitate high-quality primary care.
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Affiliation(s)
- Jong-Deuk Baek
- Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
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Garnick DW, Horgan CM, Acevedo A, McCorry F, Weisner C. Performance measures for substance use disorders--what research is needed? Addict Sci Clin Pract 2012; 7:18. [PMID: 23186374 PMCID: PMC3564737 DOI: 10.1186/1940-0640-7-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 08/31/2012] [Indexed: 11/29/2022] Open
Abstract
In 2010, the Washington Circle convened a meeting, supported by the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), for a multidisciplinary group of experts to focus on the research gaps in performance measures for substance use disorders. This article presents recommendations in three areas: development of new performance measures; methodological and other considerations in using performance measures; and implementation research focused on using performance measures for accountability and quality improvement.
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Affiliation(s)
- Deborah W Garnick
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Constance M Horgan
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Andrea Acevedo
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Frank McCorry
- Chair, Washington Circle and FAM Consulting, Yorktown Heights, NY, USA
| | - Constance Weisner
- Division of Research, Northern California Kaiser Permanente, University of California, San Francisco, CA, USA
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Hung DY, Green LA. Paying for prevention: associations between pay for performance and cessation counseling in primary care practices. Am J Health Promot 2012; 26:230-4. [PMID: 22375573 DOI: 10.4278/ajhp.091118-quan-368] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine associations between pay for performance (P4P) and recommended cessation counseling among primary care practices (PCPs). DESIGN Cross-sectional survey of 89 PCPs participating in a joint Robert Wood Johnson Foundation (RWJF)-Agency for Healthcare Research and Quality (AHRQ) health promotion initiative. SETTING AND PARTICIPANTS 100% response rate from PCPs participating in the RWJF-AHRQ initiative. MEASURES Survey data on cessation counseling, practice involvement with P4P, practice size, public reporting of performance, practice competition, linkages with community resources, integration of evidence-based guidelines, patient recommendations for cessation, and state-specific smoking rates. ANALYSIS Logistic regression was used to examine associations between practice involvement with P4P and cessation counseling offered by PCPs. Practice characteristics, including size and availability of other cessation services, were included in the analysis. RESULTS Practices that were involved with P4P had greater odds of offering recommended cessation counseling (odds ratio [OR] = 27.6, p < .01). Practices that linked patients to community resources, experienced greater competition, and were larger in size also provided more counseling (p < .05). Publicly reporting performance information and being located in states with higher smoking rates were associated with decreased odds of offering counseling support (p < .10). CONCLUSIONS Findings suggest that P4P is associated with recommended counseling for smoking cessation. Study limitations include small sample size and unavailability of information on the magnitude of P4P incentives and program design. Further analysis considering these programmatic details is warranted.
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Affiliation(s)
- Dorothy Y Hung
- Palo Alto Medical Foundation Research Institute, Health Policy Research Department, Palo Alto, California 94301, USA.
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Cohen GR, Erb N, Lemak CH. Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms. Adv Health Care Manag 2012; 13:29-58. [PMID: 23265066 DOI: 10.1108/s1474-8231(2012)0000013007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Genna R Cohen
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: Effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res 2010; 10:247. [PMID: 20731816 PMCID: PMC2936378 DOI: 10.1186/1472-6963-10-247] [Citation(s) in RCA: 302] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 08/23/2010] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Pieter Van Herck
- Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
| | - Delphine De Smedt
- Department of Public Health, Ghent University, De Pintelaan 185 Blok A-2, 9000 Gent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, De Pintelaan 185 Blok A-2, 9000 Gent, Belgium
| | - Roy Remmen
- Department of General Practice, University Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Meredith B Rosenthal
- Harvard School of Public Health, Health Policy and Management, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Walter Sermeus
- Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
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Chung S, Palaniappan L, Wong E, Rubin H, Luft H. Does the frequency of pay-for-performance payment matter?--Experience from a randomized trial. Health Serv Res 2009; 45:553-64. [PMID: 20059568 DOI: 10.1111/j.1475-6773.2009.01072.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the effects of incentive payment frequency on quality measures in a physician-specific pay-for-performance (P4P) experiment. STUDY SETTING A multispecialty physician group practice. STUDY DESIGN In 2007, all primary care physicians (n=179) were randomized into two study arms differing by the frequency of incentive payment, either four quarterly bonus checks or a single year-end bonus (maximum of U.S.$5,000/year for both arms). DATA COLLECTION/EXTRACTION METHODS Data were extracted from electronic health records. Quality measure scores between the two arms over four quarters were compared. PRINCIPAL FINDINGS There was no difference between the two arms in average quality measure score or in total bonus amount earned. CONCLUSIONS Physicians' responses to a P4P program with a small maximum bonus do not differ by frequency of bonus payment.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA 94301, USA.
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Friend KB, Levy DT, Mernoff ST. The adoption of tobacco dependence treatment by rehabilitation clinicians. Disabil Rehabil 2009; 27:147-55. [PMID: 15824044 DOI: 10.1080/09638280400007356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Individuals with disabilities tend to smoke at rates that surpass those of the general population. The Pubic Health Service Guideline on the treatment of tobacco dependence suggests that all smokers be screened at every health care visit and counselled regarding how best to quit smoking. We review the literature on the adoption of tobacco dependence treatment by rehabilitation clinicians working with disabled individuals. Despite the deleterious health effects of smoking on individuals with disabilities, the limited data suggests that rehabilitation clinicians rarely encourage their clients who smoke to quit. METHOD Studies were collected using various computerized databases from 1980 to the present. Because of the paucity of literature on tobacco dependence treatment utilization among rehabilitation clinicians, we also examine research on the use of tobacco dependence treatment by health care providers in the general population and in substance abuse treatment settings. RESULTS Despite the efficacy of tobacco dependence treatment in smokers with disabilities, tobacco dependence treatment appears to be underutilized by rehabilitation clinicians. CONCLUSIONS Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.
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Affiliation(s)
- Karen B Friend
- Pacific Institute for Research and Evaluation, Brown Medical School, Rhode Island, USA.
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Wharam JF, Paasche-Orlow MK, Farber NJ, Sinsky C, Rucker L, Rask KJ, Figaro MK, Braddock C, Barry MJ, Sulmasy DP. High quality care and ethical pay-for-performance: a Society of General Internal Medicine policy analysis. J Gen Intern Med 2009; 24:854-9. [PMID: 19294471 PMCID: PMC2695523 DOI: 10.1007/s11606-009-0947-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 12/23/2008] [Accepted: 01/26/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain. OBJECTIVE The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation. RESULTS We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients. CONCLUSION We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.
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Affiliation(s)
- J Frank Wharam
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02114, USA.
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A Multimodal Strategy Based on Pay-Per-Performance to Improve Quality of Care of Family Practitioners in Argentina. J Ambul Care Manage 2009; 32:103-14. [DOI: 10.1097/jac.0b013e31819940f7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Affiliation(s)
- George A. Diamond
- From the Division of Cardiology (G.A.D., S.K.); Cedars-Sinai Heart Institute (S.K.), Cedars-Sinai Medical Center; and the David Geffen School of Medicine (G.A.D.), University of California, Los Angeles, Calif
| | - Sanjay Kaul
- From the Division of Cardiology (G.A.D., S.K.); Cedars-Sinai Heart Institute (S.K.), Cedars-Sinai Medical Center; and the David Geffen School of Medicine (G.A.D.), University of California, Los Angeles, Calif
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Wolfson D, Bernabeo E, Leas B, Sofaer S, Pawlson G, Pillittere D. Quality improvement in small office settings: an examination of successful practices. BMC FAMILY PRACTICE 2009; 10:14. [PMID: 19203386 PMCID: PMC2649044 DOI: 10.1186/1471-2296-10-14] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 02/09/2009] [Indexed: 11/13/2022]
Abstract
Background Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives. Methods We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities. Results Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers. Conclusion These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.
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Affiliation(s)
- Daniel Wolfson
- Quality Research, American Board of Internal Medicine, Philadelphia, PA, USA.
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Hamblin R. Regulation, measurements and incentives. The experience in the US and UK: does context matter? ACTA ACUST UNITED AC 2009; 128:291-8. [PMID: 19058469 DOI: 10.1177/1466424008096617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since the 1990s the US and UK healthcare systems have increasingly sought to measure the quality of services in order to stimulate improvement and publish the results. Despite the very different healthcare systems, there are some striking similarities in the results of these schemes. In both countries information that creates the threat of reputational damage and the possibility of gaining kudos is particularly effective in stimulating a response. However, these responses may be perverse: gaming, falsifying of data and measurement fixation have all been uncovered. In the UK context, information is closely aligned to the regulatory and performance management framework, and there should be a role for the new Care Quality Commission in the emerging 'information landscape' of the NHS in England.
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Affiliation(s)
- Richard Hamblin
- Healthcare Commission, Finsbury Tower, 103-705 Bunhill Row, London EC1Y 8TG, UK.
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Christianson JB, Leatherman S, Sutherland K. Lessons From Evaluations of Purchaser Pay-for-Performance Programs. Med Care Res Rev 2008; 65:5S-35S. [DOI: 10.1177/1077558708324236] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There has been a growing interest in the use of financial incentives to encourage improvements in the quality of health care. Several articles have reviewed past studies of the impact of specific incentive arrangements, but these studies addressed small-scale experiments, making their findings arguably of limited relevance to current improvement efforts. In this article, the authors review evaluations of more recent pay-for-performance initiatives instituted by health plans or by provider organizations in cooperation with health plans. Findings show improvement in selected quality measures in most of these initiatives, but the contribution of financial incentives to that improvement is not clear; the incentives typically were implemented in conjunction with other quality improvement efforts, or there was not a convincing comparison group. However, the literature relating to purchaser pay-for-performance initiatives does underscore several important issues that deserve attention going forward that relate to the design and implementation of pay-for-performance initiatives.
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Holtrop JS, Malouin R, Weismantel D, Wadland WC. Clinician perceptions of factors influencing referrals to a smoking cessation program. BMC FAMILY PRACTICE 2008; 9:18. [PMID: 18373854 PMCID: PMC2323376 DOI: 10.1186/1471-2296-9-18] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 03/28/2008] [Indexed: 12/04/2022]
Abstract
Background Referral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial. Methods We conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets. Results As compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral. Conclusion Further research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources. Trial Registration Number Clinicaltrials.gov NCT00529256
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, Michigan State University, B101 Clinical Center, East Lansing MI 48824, USA.
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Gilmore AS, Zhao Y, Kang N, Ryskina KL, Legorreta AP, Taira DA, Chung RS. Patient outcomes and evidence-based medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program. Health Serv Res 2007; 42:2140-59; discussion 2294-323. [PMID: 17995557 PMCID: PMC2151397 DOI: 10.1111/j.1475-6773.2007.00725.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine whether health plan members who saw physicians participating in a quality-based incentive program in a preferred provider organization (PPO) setting received recommended care over time compared with patients who saw physicians who did not participate in the incentive program, as per 11 evidence-based quality indicators. DATA SOURCES/STUDY SETTING Administrative claims data for PPO members of a large nonprofit health plan in Hawaii collected over a 6-year period after the program was first implemented. STUDY DESIGN An observational study allowing for multiple member records within and across years. Levels of recommended care received by members who visited physicians who did or did not participate in a quality incentive program were compared, after controlling for other member characteristics and the member's total number of annual office visits. DATA COLLECTION Data for all PPO enrollees eligible for at least one of the 11 quality indicators in at least 1 year were collected. PRINCIPAL FINDINGS We found a consistent, positive association between having seen only program-participating providers and receiving recommended care for all 6 years with odds ratios ranging from 1.06 to 1.27 (95 percent confidence interval: 1.03-1.08, 1.09-1.40). CONCLUSIONS Physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether or not a patient receives high quality, recommended care.
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Christianson JB. Evaluating pay-for-performance in medicaid through real-world observation. Health Aff (Millwood) 2007; 26:w528-31. [PMID: 17595199 DOI: 10.1377/hlthaff.26.4.w528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health services researchers use a variety of methods to answer questions surrounding the use of incentives for quality. The current work by Suzanne Felt-Lisk and colleagues suffers from some limitations that may be inherent to many kinds of research, but it also overcomes a number of limitations and offers important insights into why some pay-for-performance (P4P) efforts are more successful than others. The work contributes to Medicaid payment policy and to the P4P literature more generally. In the future, it will be important for researchers to build on "exploratory" observational studies like those of Felt-Lisk and colleagues' study and others by testing explicit "behavioral models" of individual physician or physician practice responses to P4P.
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Young GJ, Meterko M, Beckman H, Baker E, White B, Sautter KM, Greene R, Curtin K, Bokhour BG, Berlowitz D, Burgess JF. Effects of paying physicians based on their relative performance for quality. J Gen Intern Med 2007; 22:872-6. [PMID: 17443360 PMCID: PMC2219885 DOI: 10.1007/s11606-007-0185-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 11/27/2006] [Accepted: 03/15/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. OBJECTIVE The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. PARTICIPANTS There were 334 participating primary care physicians in Rochester, New York. DESIGN The design of the study is a retrospective cohort study using pre/post analysis. MEASUREMENTS The measurements adhere to 4 diabetes performance measures between 1999 and 2004. RESULTS While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. CONCLUSIONS This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.
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Affiliation(s)
- Gary J Young
- Department of Health Policy and Management, Boston University School of Public Health, Talbot Building, 715 Albany Street, Boston, MA 02118-2526, USA.
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Wadland WC, Holtrop JS, Weismantel D, Pathak PK, Fadel H, Powell J. Practice-based referrals to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders. Ann Fam Med 2007; 5:135-42. [PMID: 17389537 PMCID: PMC1838696 DOI: 10.1370/afm.650] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to assess the impact of comparative feedback vs general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for projected quit responses. METHODS We conducted a group-randomized clinical trial comparing the impact of 6 quarterly (18 months) feedback reports (intervention) with that of general reminders (control) on practice-based clinician referrals to a quit-line service. Feedback reports were based on an Achievable Benchmark of Care approach using baseline practice, clinician, and patient survey responses, and referrals per quarter. Comparable quit responses and costs were estimated. RESULTS Three hundred eight clinicians participated (171 family medicine, 88 internal medicine, 49 obstetrics-gynecology) from 87 primary care practices in Michigan. After 18 months, there were more referrals from the intervention than from the control practices (484 vs 220; P <.001). Practice facsimile (fax) referrals (84%, n = 595) exceeded telephone referrals (16%, n = 109), but telephone referrals resulted in greater likelihood of enrollment (77% telephone vs 44% fax, P <.001). The estimated number of smokers who quit based on the level of services utilized by referred smokers was 66 in the feedback and 36 in the gentle reminder practices. CONCLUSION Providing comparative feedback on clinician referrals to a quit-line service had a modest impact with limited increased costs.
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Affiliation(s)
- William C Wadland
- Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, MI 48824-1313, USA.
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Frølich A, Talavera JA, Broadhead P, Dudley RA. A behavioral model of clinician responses to incentives to improve quality. Health Policy 2007; 80:179-93. [PMID: 16624440 DOI: 10.1016/j.healthpol.2006.03.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 03/06/2006] [Indexed: 10/24/2022]
Abstract
The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.
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Affiliation(s)
- Anne Frølich
- Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Brush JE, Krumholz HM, Wright JS, Brindis RG, Cacchione JG, Drozda JP, Fasules JW, Flood KB, Garson A, Masoudi FA, McBride T, McKay CR, Messer JV, Mirro MJ, O'Toole MF, Peterson ED, Schaeffer JW, Valentine CM. American College of Cardiology 2006 Principles to Guide Physician Pay-for-Performance Programs. J Am Coll Cardiol 2006; 48:2603-9. [PMID: 17174211 DOI: 10.1016/j.jacc.2006.10.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Despite more than a decade of bench-marking and public reporting of quality problems in the health care sector, changes in medical practice have been slow to materialize. To accelerate quality improvement, many private and public payers have begun to offer financial incentives to physicians and hospitals based on their performance on clinical and service quality measures. The authors review the empirical literature on paying for quality in health care and comparable interventions in other sectors. They find little evidence to support the effectiveness of paying for quality. The absence of findings for an effect may be attributable to the small size of the bonuses studied and the fact that payers often accounted for only a fraction of the targeted provider's panel. Even in non-health settings, however, where the institutional features are more favorable to a positive impact, the literature contains mixed results on the effectiveness of analogous pay-for-performance schemes.
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Affiliation(s)
- Joel A DeLisa
- Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, West Orange, New Jersey 07052, USA
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31
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Rosenthal MB, Fernandopulle R, Song HR, Landon B. Paying For Quality: Providers’ Incentives For Quality Improvement. Health Aff (Millwood) 2004; 23:127-41. [PMID: 15046137 DOI: 10.1377/hlthaff.23.2.127] [Citation(s) in RCA: 267] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paying health care providers to meet quality goals is an idea with widespread appeal, given the common perception that quality of care in the United States remains unacceptably low despite a decade of benchmarking and public reporting. There has been little critical analysis of the design of the current generation of quality incentive programs. In this paper we examine public reports of paying for quality over the past five years and assess each of the identified programs in terms of key design features, including the market share of payers, the structure of the reward system, the amount of revenue at stake, and the targeted domains of health care quality.
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Affiliation(s)
- Meredith B Rosenthal
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
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