Does Paying for Performance Improve the Quality of Health Care?

Hospital performance trends on national quality measures and the association with Joint Commission accreditation

BACKGROUND

Evaluations of the impact of hospital accreditation have been previously hampered by the lack of nationally standardized data. One way to assess this impact is to compare accreditation status with other evidence-based measures of quality, such as the process measures now publicly reported by The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).

OBJECTIVES

To examine the association between Joint Commission accreditation status and both absolute measures of, and trends in, hospital performance on publicly reported quality measures for common diseases.

DESIGN, SETTING, AND PATIENTS

Performance data for 2004 and 2008 from U.S. acute care and critical access hospitals were obtained using publicly available CMS Hospital Compare data augmented with Joint Commission performance data.

MEASUREMENTS

Changes in hospital performance between 2004 and 2008, and percent of hospitals with 2008 performance exceeding 90% for 16 measures of quality-of-care and 4 summary scores.

RESULTS

Hospitals accredited by The Joint Commission tended to have better baseline performance in 2004 than non-accredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores.

CONCLUSIONS

While Joint Commission-accredited hospitals already outperformed non-accredited hospitals on publicly reported quality measures in the early days of public reporting, these differences became significantly more pronounced over 5 years of observation. Future research should examine whether accreditation actually promotes improved performance or is a marker for other hospital characteristics associated with such performance. Journal of Hospital Medicine 2011;6:458-465. © 2011 Society of Hospital Medicine.

Pay for performance in Medicare: evidentiary irony and the politics of value

Pay for performance (P4P) is of growing importance in the Medicare program. Pay-for-performance policy has the support of political actors in both parties and in the legislative and executive branches; of experts, business, and consumer interests; and in a qualified way, of health care providers. The evidence that P4P improves quality or reduces cost, however, is scant, although P4P proponents claim that the program is evidence based. This article reviews the history of Medicare P4P, documents its widespread support, and evaluates both the evidence of its effectiveness and the expert discourse about that evidence. The article analyzes the political reasons for Medicare P4P's popularity despite its evidentiary deficiencies and emphasizes its role in the politics of value. Pay for performance allows Medicare policy makers to (1) reformulate intractable cost and quality problems as more malleable value problems; (2) offer an acceptable quid pro quo for payment negotiations with providers; and (3) reach a rare, if shallow, consensus based on the ideological ambiguity of P4P.

Pay for performance in the intensive care unit--opportunity or threat?

OBJECTIVE

Ongoing evidence of poor-quality healthcare has stimulated the development of provider reimbursement schemes linked to the delivery of high-quality care. Our objective was to describe these programs and their potential implementation in intensive care units (ICUs).

SOURCES

MEDLINE (2000-May, 2008) and personal files.

STUDY SELECTION

We selected empirical studies, narrative and systematic reviews, and commentaries addressing pay-for-performance programs.

DATA EXTRACTION

Using a narrative review format, we discuss the definition of pay-for-performance, describe current implementations, suggest challenges of applying these programs to the ICU setting, and discuss alternative quality improvement programs.

DATA SYNTHESIS

The ICU will likely become a target for pay-for-performance plans, considering the high cost of care, development of ICU quality-of-care measures, and interest from healthcare regulators and funders. Existing plans applied outside the ICU have varied in the amount of financial incentive and targeted provider and quality measures. Evaluations are sparse. Implementation challenges specific to the ICU include selecting evidence-based and feasible quality of care measures, motivating the entire interdisciplinary team, integrating multifaceted behavior change strategies, and developing informatics infrastructure for timely audit and feedback. Other incentive-based alternatives to improve ICU quality of care include a "centers of excellence" approach (referral of patients to centers with excellent outcomes), public reporting of ICU outcomes, and payments to hospitals for participating in quality improvement programs.

CONCLUSIONS

Participation in pay-for-performance programs is a potential opportunity for intensivists and ICU teams to improve outcomes for their patients in partnership with regulatory agencies and healthcare funders. Because many aspects of optimal design of these programs in ICUs are unknown, robust evaluations of their effect on healthcare quality should be integrated into any implementations.

Getting real performance out of pay-for-performance

CONTEXT

Most private and public health insurers are implementing pay-for-performance (P4P) programs in an effort to improve the quality of medical care. This article offers a paradigm for evaluating how P4P programs should be structured and how effective they are likely to be.

METHODS

This article assesses the current comprehensiveness of evidence-based medicine by estimating the percentage of outpatient medical spending for eighteen medical processes recommended by the Institute of Medicine.

FINDINGS

Three conditions must be in place for outcomes-based P4P programs to improve the quality of care: (1) health insurers must not fully understand what medical processes improve health (i.e., the health production function); (2) providers must know more about the health production function than insurers do; and (3) health insurers must be able to measure a patient's risk-adjusted health. Only two of these conditions currently exist. Payers appear to have incomplete knowledge of the health production function, and providers appear to know more about the health production function than payers do, but accurate methods of adjusting the risk of a patient's health status are still being developed.

CONCLUSIONS

This article concludes that in three general situations, P4P will have a different impact on quality and costs and so should be structured differently. When information about patients' health and the health production function is incomplete, as is currently the case, P4P payments should be kept small, should be based on outcomes rather than processes, and should target physicians' practices and health systems. As information improves, P4P incentive payments could be increased, and P4P may become more powerful. Ironically, once information becomes complete, P4P can be replaced entirely by "optimal fee-for-service."

Patient opinions regarding 'pay for performance for patients'

BACKGROUND

Pay for performance (P4P) programs have shown only modest improvements in outcomes and do not target patient behaviors. Many large employers and payers are turning to pay for performance for patients (P4P4P) to reduce health costs and improve the health of their covered populations. How these programs may be perceived by patients is unknown.

OBJECTIVE

To assess patients' opinion of the acceptability of P4P4P.

DESIGN

Cross-sectional self-administered survey.

PARTICIPANTS

Patients in waiting rooms in two university-based primary care clinics.

MEASUREMENTS

Participants were asked their opinions about paying people to quit smoking, lose weight, control their blood pressure, or control their diabetes.

RESULTS

Respondents were split on whether P4P4P is desirable. Thirty-six to 42% thought it was a good/excellent idea to pay smokers to quit smoking, obese people to lose weight, people with hypertension to control their blood pressure, or people with diabetes to control their blood sugar, while 41-44% of the sample thought it was a bad/very bad idea. Smokers and patients who were obese endorsed P4P4P more favorably as a means to achieving tobacco cessation and weight loss than their non-smoking and non-obese counterparts.

CONCLUSIONS

Acceptance of paying patients for performance by the general population is equivocal. Establishing the efficacy of paying patients for performance may help it gain wider acceptance.

Does pay-for-performance influence the quality of care?

PURPOSE OF REVIEW

To summarize studies of pay-for-performance programmes designed to address clinical quality of care markers in ambulatory settings at the level of the physician group or individual physician.

RECENT FINDINGS

Seven randomized controlled trials and 15 nonrandomized studies were reviewed. Less than half of the randomized controlled trials showed positive results, whereas all but one of the nonrandomized studies showed positive or mixed results. Characteristics of the quality measures, incentives, providers, patients, and concurrent interventions probably influenced the results. Study methodology problems such as small sample sizes, selection bias, and inadequate control for confounders were common. Asthma quality of care markers were included in three nonrandomized studies, two of which showed positive results and one of which was negative.

SUMMARY

The data reviewed in this article suggest that pay-for-performance programmes can improve markers of quality, though not always. Even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives as compared with other factors. More and better-designed studies are needed to determine the actual effectiveness of incentives themselves isolated from other factors, circumstances that promote effectiveness, effectiveness relative to other strategies, and cost-effectiveness.

Patient outcomes and evidence-based medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program

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.

What can we do about low colorectal cancer screening rates?

The prevalence of colorectal cancer screening is not what it needs to be. Whether screening takes place according to a medical practice model or a public health model, we need to systematically evaluate interventions to increase screening adherence, identify predictors of screening uptake, and identify the reasons for nonadherence. A largely untapped opportunity exists for gastroenterologists to collaborate with behavioral scientists to conduct this research.

Effects of paying physicians based on their relative performance for quality

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.

Heterogeneity of treatment effects: implications for guidelines, payment, and quality assessment

Randomized controlled trial results are needed for developing guidelines, payment rules, and quality-of-care measures; however, 2 phenomena reduce the usefulness of randomized controlled trial findings. First, these studies now enroll patients with less severe disease, who are less likely to benefit from a drug or treatment. Second, patients are living longer but, as a result, have more chronic diseases. Although randomized controlled trials often exclude these older patients, trial findings continue to be generalized to them. Together, these phenomena impose challenges to the usefulness of the results of randomized controlled trials for clinical and policy applications. The convergence of these phenomena makes the current research paradigm underlying evidence-based medicine, guideline development and quality assessment fundamentally flawed in 2 ways. First, the "evidence" includes patients who may have a minimal benefit from the treatment being tested. This could reduce the power for the trial and yield negative or null results, leading to undertreatment of a group of patients with potential for a greater-than-observed benefit. Second, attempts to generalize the results from positive trials to patients who have been excluded from those trials may result in the overtreatment of those who could not benefit (e.g., because they will die from other causes before the benefit of treatment would occur) and therefore represents a parallel hazard. In this article, we describe sources of heterogeneity of treatment effects (HTE) within trials, which can compromise the interpretation and generalizability of results. We also examine strategies for understanding and managing HTE in practice, to increase the usefulness of trial results.