Pay for Performance Improves Quality Across Demographic Groups

Financial Interventions to Improve Screening in Primary Care: A Systematic Review

INTRODUCTION

Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question.

METHODS

Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing).

RESULTS

Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4).

DISCUSSION

Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

From quality improvement to equality improvement projects: A scoping review and framework

Increasing awareness of health disparities has led to proposals for a pay-for-equity scheme. Implementing such proposals requires systematic methods of collecting and reporting health outcomes for targeted demographics over time. This lays the foundation for a shift from quality improvement projects (QIPs) to equality improvement projects (EQIPs) that could evaluate adherence to standards and progress toward health equity. We performed a scoping review on EQIPs to inform a new framework for quality improvement through a health equity lens. Forty studies implemented an intervention after identifying a disparity compared to 149 others which merely identified group differences. Most evaluated race-based differences and were conducted at the institutional level, with representation in both the inpatient and outpatient settings. EQIPs that improved equity leveraged multidisciplinary expertise, healthcare staff education, and developed tools to track health outcomes continuously. EQIPs can help bridge the inequality gap and form part of an incentivized systematic equality improvement framework.

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

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

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

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

OBJECTIVE

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

DATA SOURCE/STUDY SETTING

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

STUDY DESIGN

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

DATA COLLECTION/EXTRACTION METHOD

Data collected electronically and by chart review.

PRINCIPAL FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

Pay-for-Performance: Disappointing Results or Masked Heterogeneity?

Research on the effects of pay-for-performance (P4P) in health care indicates largely disappointing results. This central finding, however, may mask important heterogeneity in the effects of P4P. We conducted a literature review to assess whether hospital and physician performance in P4P vary by patient and catchment area factors, organizational and structural capabilities, and P4P program characteristics. Several findings emerged: organizational size, practice type, teaching status, and physician age and gender modify performance in P4P. For physician practices and hospitals, a higher proportion of poor and minority patients is consistently associated with worse performance. Other theoretically influential characteristics-including information technology and staffing levels-yield mixed results. Inconsistent and contradictory effects of bonus likelihood, bonus size, and marginal costs on performance in P4P suggest organizations have not responded strategically to financial incentives. We conclude that extant heterogeneity in the effects of P4P does not fundamentally alter current assessments about its effectiveness.

Influence of a Pay-for-Performance Program on Glycemic Control in Patients Living with Diabetes by Family Physicians in a Canadian Province

OBJECTIVES

We evaluated the influence of the introduction of a pay-for-performance program implemented in 2010 for family physicians on the glycemic control of patients with diabetes.

METHODS

Administrative data for all 583 eligible family physicians and 83,580 adult patients with diabetes in New Brunswick over 10 years were used. We compared the probability of receiving at least 2 tests for glycated hemoglobin (A1C) levels and achieving glycemic control before (2005-2009) and after (2010-2014) the implementation of the program and between patients divided based on whether a physician claimed the incentive or did not.

RESULTS

Patients living with diabetes showed greater odds of receiving at least 2 A1C tests per year if the detection of their diabetes occurred after (vs. before) the implementation of the program (OR, 99% CI=1.23, 1.18 to 1.28), if a physician claimed the incentive (vs. not claiming it) for their care (1.92, 1.87 to 1.96) in the given year, and if they were followed by a physician who ever (vs. never) claimed the incentive (1.24, 1.15 to 1.34). In a cohort-based analysis, patients for whom an incentive was claimed (vs. not claimed) had greater odds of receiving at least 2 A1C tests per year before implementation of the incentive, and these odds increased by 56% (1.49 to 1.62) following its implementation. However, there was no difference in A1C values among the various comparison groups.

CONCLUSIONS

Introduction of the incentive was associated with greater odds of having a minimum of 2 A1C tests per year, which may suggest that it led physicians to provide better follow-up care for patients with diabetes. However, the incentive program has not been associated with differences in glycemic control.

Financial Incentives to Encourage Value-Based Health Care

This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.

The impact of reimbursement systems on equity in access and quality of primary care: A systematic literature review

BACKGROUND

Reimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care.

METHODS

A systematic search was performed in Web of Science and PubMed for English language studies published between 1980 and 2013, supplemented by reference tracking. Articles were selected based on inclusion criteria, and data extraction and critical appraisal were performed by two authors independently. Data were synthesized in a narrative manner and categorized according to study outcome and reimbursement system.

RESULTS

Twenty seven articles, mostly from the United States and United Kingdom, were included in the data synthesis. Reimbursement systems seem to have limited effect on socioeconomic and racial inequity in access, utilization and quality of primary care. Capitation might have a more beneficial impact on inequity in access to primary care and number of ambulatory care sensitive admissions than fee-for-service, but did worse in patient satisfaction. Pay-for-performance had little or no impact on socioeconomic and racial inequity in the management of diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, and preventive services.

CONCLUSION

We found little scientific evidence supporting an association between reimbursement system and socioeconomic or racial inequity in access, utilization and quality of primary care. Overall, few studies addressed this research question, and heterogeneity in context and outcomes complicates comparisons across studies. Further empirical studies are warranted.

Racial disparities in outcomes after cardiac surgery: the role of hospital quality

Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.

Quality of care among patients undergoing lower extremity revascularization

BACKGROUND

Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010.

METHODS

Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received.

RESULTS

Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death.

CONCLUSIONS

Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.