Paying For Performance In Primary Care: Potential Impact On Practices And Disparities

Perceptions of nurses and physicians on pay-for-performance in hospital: a systematic review of qualitative studies

AIMS

To systematically examine perceptions of nurses and physicians on pay-for-performance in hospital.

BACKGROUND

Pay-for-performance projects have proliferated over the past two decades, most systematic reviews of which solely focused on its effectiveness in primary healthcare and the physicians' or nurses' attitudes. However, systematic reviews of qualitative approaches for better examining perceptions of both nurses and physicians in hospital are lacking.

EVALUATION

Electronic databases were systematic searched with date from its inception to December 31, 2020. Meta-aggregation synthesis methodology and the conceptual framework of the Theory of Planned Behavior were used to summarize findings.

KEY ISSUES

A total of nine studies were included. Three major synthesized themes were identified: (1) perceptions of the motivation effects and positive outcomes (2) perceptions about the design defects and negative effects (3) perceptions of the obstacles in the implementation process.

CONCLUSION

To maximize the intended positive effects, nurses' and physicians' perceptions should be considered and incorporated into the project design and implementation stage.

IMPLICATIONS FOR NURSING MANAGEMENT AND RESEARCH

The paper gives enlightenment to nurse managers on improving and advancing the cause of nurses when planning for or evaluating their institutions' policies on pay-for-performance in the future research.

Why Money Alone Can’t (Always) “Nudge” Physicians

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Lower- Versus Higher-Income Populations In The Alternative Quality Contract: Improved Quality And Similar Spending

As population-based payment models become increasingly common, it is crucial to understand how such payment models affect health disparities. We evaluated health care quality and spending among enrollees in areas with lower versus higher socioeconomic status in Massachusetts before and after providers entered into the Alternative Quality Contract, a two-sided population-based payment model with substantial incentives tied to quality. We compared changes in process measures, outcome measures, and spending between enrollees in areas with lower and higher socioeconomic status from 2006 to 2012 (outcome measures were measured after the intervention only). Quality improved for all enrollees in the Alternative Quality Contract after their provider organizations entered the contract. Process measures improved 1.2 percentage points per year more among enrollees in areas with lower socioeconomic status than among those in areas with higher socioeconomic status. Outcome measure improvement was no different between the subgroups; neither were changes in spending. Larger or comparable improvements in quality among enrollees in areas with lower socioeconomic status suggest a potential narrowing of disparities. Strong pay-for-performance incentives within a population-based payment model could encourage providers to focus on improving quality for more disadvantaged populations.

The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities

BACKGROUND

When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average.

OBJECTIVE

To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients.

DESIGN

Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics.

SETTING

Fee-for-service Medicare.

PATIENTS

Random 20% sample of beneficiaries.

MEASUREMENTS

Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality.

RESULTS

No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores.

LIMITATION

Observational design and administrative data.

CONCLUSION

The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities.

PRIMARY FUNDING SOURCE

The Laura and John Arnold Foundation and National Institute on Aging.

Incentive Design and Quality Improvements: Evidence from State Medicaid Nursing Home Pay-for-Performance Programs

Pay-for-performance (P4P) programs have become a popular policy tool aimed at improving health care quality. We analyze how incentive design affects quality improvements in the nursing home setting, where several state Medicaid agencies have implemented P4P programs that vary in incentive structure. Using the Minimum Data Set and the Online Survey, Certification, and Reporting data from 2001 to 2009, we examine how the weights put on various performance measures that are tied to P4P bonuses, such as clinical outcomes, inspection deficiencies, and staffing levels, affect improvements in those measures. We find larger weights on clinical outcomes often lead to larger improvements, but small weights can lead to no improvement or worsening of some clinical outcomes. We find a qualifier for P4P eligibility based on having few or no severe inspection deficiencies is more effective at decreasing inspection deficiencies than using weights, suggesting simple rules for participation may incent larger improvement.

Influencing quality of outpatient SUD care: Implementation of alerts and incentives in Washington State

Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control.

Accounting for multimorbidity in pay for performance: a modelling study using UK Quality and Outcomes Framework data

BACKGROUND

The UK Quality and Outcomes Framework (QOF) offers financial incentives to deliver high-quality care for individual diseases, but the single-disease focus takes no account of multimorbidity.

AIM

To examine variation in QOF payments for two indicators incentivised in ≥1 disease domain.

DESIGN AND SETTING

Modelling study using cross-sectional data from 314 general practices in Scotland.

METHOD

Maximum payments that practices could receive under existing financial incentives were calculated for blood pressure (BP) control and influenza immunisation according to the number of coexisting clinical conditions. Payments were recalculated assuming a single new indicator.

RESULTS

Payment varied by condition (£4.71-£11.08 for one BP control and £2.09-£5.78 for one influenza immunisation). Practices earned more for delivering the same action in patients with multimorbidity: in patients with 2, 3, and ≥4 conditions mean payments were £13.95, £21.92, and £29.72 for BP control, and £7.48, £11.21, and £15.14 for influenza immunisation, respectively. Practices in deprived areas had more multiple incentivised patients. When recalculated so that each incentivised action was only paid for once, all practices received less for BP control: affluent practices received more and deprived practices received less for influenza immunisation.

CONCLUSION

For patients with single conditions, existing QOF payment methods have more than twofold variation in payment for delivering the same process. Multiple payments were common in patients with multimorbidity. A payment method is required that ensures fairness of rewards while maintaining adequate funding for practices based on actual workload.

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?

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.

Measuring quality in pediatrics: Florida's early experiences with the CHIPRA core measure set

Enacted in 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA) aims, among other things, to increase state's accountability for providing quality health care to all children in the United States. Although it is important for states to report on the measures, learning from their successes and failures is critical in producing the measures so that states will be prepared for future regulations. Florida covered roughly 2.59 million children in 2010. Administrative, medical record, registry, and survey data were used to report on 20 of the 24 CHIPRA core measures. Technical specifications from the Centers for Medicare and Medicaid Services were used. Approximately 10 months were needed to identify, collect, safeguard, and process the required data. Florida was able to build on its past experiences with performance measurement reporting and surveying. Conducting medical record reviews at the state level and producing measures that required registry data proved to be challenging. Although Florida was successful in its first year of reporting the CHIPRA core measures, certain populations were not included in some of the measures. The next phase of Florida's CHIPRA project will focus on developing and implementing a dissemination plan and creating opportunities to improve the measures. Florida has made significant progress in the early phases of reporting the CHIPRA measures. As Florida gains more experience in reporting the measures, and results from other states are released, it will be easier to put the statewide measure results into context. Once meaningful comparisons can be made, Florida will be able to better plan for the future of child health and health outcomes.

Partnering health disparities research with quality improvement science in pediatrics

Disparities in pediatric health care quality are well described in the literature, yet practical approaches to decreasing them remain elusive. Quality improvement (QI) approaches are appealing for addressing disparities because they offer a set of strategies by which to target modifiable aspects of care delivery and a method for tailoring or changing an intervention over time based on data monitoring. However, few examples in the literature exist of QI interventions successfully decreasing disparities, particularly in pediatrics, due to well-described challenges in developing, implementing, and studying QI with vulnerable populations or in underresourced settings. In addition, QI interventions aimed at improving quality overall may not improve disparities, and in some cases, may worsen them if there is greater uptake or effectiveness of the intervention among the population with better outcomes at baseline. In this article, the authors review some of the challenges faced by researchers and frontline clinicians seeking to use QI to address health disparities and propose an agenda for moving the field forward. Specifically, they propose that those designing and implementing disparities-focused QI interventions reconsider comparator groups, use more rigorous evaluation methods, carefully consider the evidence for particular interventions and the context in which they were developed, directly engage the social determinants of health, and leverage community resources to build collaborative networks and engage community members. Ultimately, new partnerships between communities, providers serving vulnerable populations, and QI researchers will be required for QI interventions to achieve their potential related to health care disparity reduction.

Management commitments and primary care: another lesson from Costa Rica for the world?

Maintained dedication to primary care has fostered a public health delivery system with exceptional outcomes in Costa Rica. For more than a decade, management commitments have been part of Costa Rican health reform. We assessed the effect of the Costa Rican management commitments on access and quality of care and on compliance with their intended objectives. We constructed seven hypotheses on opinions of primary care providers. Through a mixed qualitative and quantitative approach, we tested these hypotheses and interpreted the research findings. Management commitments consume an excessive proportion of consultation time, inflate recordkeeping, reduce comprehensiveness in primary care consultations, and induce a disproportionate consumption of hospital emergency services. Their formulation relies on norms in need of optimization, their control on unreliable sources. They also affect professionalism. In Costa Rica, management commitments negatively affect access and quality of care and pose a threat to the public service delivery system. The failures of this pay-for-performance-like initiative in an otherwise well-performing health system cast doubts on the appropriateness of pay-for-performance for health systems strengthening in less advanced environments.

Pay-for-Performance: Toxic to Quality? Insights from Behavioral Economics

Pay-for-performance programs aim to upgrade health care quality by tailoring financial incentives for desirable behaviors. While Medicare and many private insurers are charging ahead with pay-for-performance, researchers have been unable to show that it benefits patients. Findings from the new field of behavioral economics challenge the traditional economic view that monetary reward either is the only motivator or is simply additive to intrinsic motivators such as purpose or altruism. Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that pay-for-performance may backfire.

Specialties differ in which aspects of doctor communication predict overall physician ratings

BACKGROUND

Effective doctor communication is critical to positive doctor-patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty.

OBJECTIVE

To determine the importance of five aspects of doctor communication to overall physician ratings by specialty.

DESIGN

For each of 28 specialties, we calculated partial correlations of five communication items with a 0-10 overall physician rating, controlling for patient demographics.

PATIENTS

Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) 12-month Survey data collected 2005-2009 from 58,251 adults at a 534-physician medical group.

MAIN MEASURES

CG-CAHPS includes a 0 ("Worst physician possible") to 10 ("Best physician possible") overall physician rating. Five doctor communication items assess how often the physician: explains things; listens carefully; gives easy-to-understand instructions; shows respect; and spends enough time.

KEY RESULTS

Physician showing respect was the most important aspect of communication for 23/28 specialties, with a mean partial correlation (0.27, ranging from 0.07 to 0.44 across specialties) that accounted for more than four times as much variance in the overall physician rating as any other communication item. Three of five communication items varied significantly across specialties in their associations with the overall rating (p < 0.05).

CONCLUSIONS

All patients valued respectful treatment; the importance of other aspects of communication varied significantly by specialty. Quality improvement efforts by all specialties should emphasize physicians showing respect to patients, and each specialty should also target other aspects of communication that matter most to their patients. The results have implications for improving provider quality improvement and incentive programs and the reporting of CAHPS data to patients. Specialists make important contributions to coordinated patient care, and thus customized approaches to measurement, reporting, and quality improvement efforts are important.

Simulation models for socioeconomic inequalities in health: a systematic review

Background: The emergence and evolution of socioeconomic inequalities in health involves multiple factors interacting with each other at different levels. Simulation models are suitable for studying such complex and dynamic systems and have the ability to test the impact of policy interventions in silico. Objective: To explore how simulation models were used in the field of socioeconomic inequalities in health. Methods: An electronic search of studies assessing socioeconomic inequalities in health using a simulation model was conducted. Characteristics of the simulation models were extracted and distinct simulation approaches were identified. As an illustration, a simple agent-based model of the emergence of socioeconomic differences in alcohol abuse was developed. Results: We found 61 studies published between 1989 and 2013. Ten different simulation approaches were identified. The agent-based model illustration showed that multilevel, reciprocal and indirect effects of social determinants on health can be modeled flexibly. Discussion and Conclusions: Based on the review, we discuss the utility of using simulation models for studying health inequalities, and refer to good modeling practices for developing such models. The review and the simulation model example suggest that the use of simulation models may enhance the understanding and debate about existing and new socioeconomic inequalities of health frameworks.

Diabetes care quality is highly correlated with patient panel characteristics

INTRODUCTION

Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs).

METHODS

Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined.

RESULTS

Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators.

CONCLUSIONS

Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.

Incentivizing primary care providers to innovate: building medical homes in the post-Katrina New Orleans safety net

OBJECTIVE

To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans.

DATA SOURCES/STUDY SETTING

Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery.

STUDY DESIGN

Multiwave, longitudinal, observational study of a local safety-net primary care system.

DATA COLLECTION

Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records.

PRINCIPAL FINDINGS

Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall.

CONCLUSIONS

Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation.

Key issues in the design of pay for performance programs

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages "selection" and "teaching to the test" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally "decoupled" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.

The post-Katrina conversion of clinics in New Orleans to medical homes shows change is possible, but hard to sustain

Hurricane Katrina destroyed much of the health care infrastructure in and around New Orleans in 2005. We describe a natural experiment that occurred afterward, amid efforts to rebuild the city's health care system, in which diverse safety-net clinics were transformed into medical homes. Using surveys of clinic leaders and administrative data, we found that clinics made substantial progress in implementing new clinical processes to improve access, quality and safety, and care coordination and integration. But there was wide variation, with some clinics making only minimal progress. Because the transformation was closely tied to the receipt of federal grants and bonus payments, we observed declines in performance toward the end of the study, when clinics faced diminished federal funding and refocused their priorities on survival. Now that federal funds have dried up, moreover, clinics may be losing ground in sustaining their practice changes. The experience shows that payment to support medical home transformation must be robust and stable, and clinics need to be fully integrated into the broader health care system to improve overall coordination of care.

Methodological challenges of measuring primary care delivery to pediatric medicaid beneficiaries who use community health centers

Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance.

Does a diabetes annual review make a difference?

AIMS

To determine whether a diabetes annual review, independently of other care processes, is followed by improved patient clinical measurements.

METHODS

Audits conducted independently of the diabetes annual review were analysed for a time-trend in patient clinical measures. An interaction variable between the review and the year of audit was used to test for a change in gradient before and after a diabetes annual review. Each patient formed their own control.

RESULTS

The data included 9471 audits on 3397 patients from 92 practices, and diabetes annual reviews from 2003 to mid-2008. Percentages of patients with raised HbA(1c) , systolic blood pressure and lipids improved from first to last audit. Predicted means after a diabetes annual review for HbA(1c) decreased by 0.13% (1.0 mmol/mol), for HDL cholesterol increased by 0.04 mmol/L and for triglyceride decreased by 0.2 mmol/L. Predicted systolic and diastolic blood pressure, total cholesterol and urinary albumin:creatinine ratio did not change significantly.

CONCLUSIONS

Metabolic control improved over time but this was largely independently of the diabetes annual review, which appears to add little clinical value to existing New Zealand general practice care processes. Currently, general practitioners are paid to undertake a diabetes annual review and report the measurements collected. We would argue that payment needs to be directed to demonstrating appropriate changes in clinical management or achieving meaningful clinical goals, and that the annual review results should be part of systematic feedback to general practitioners, particularly directed at clinical inertia.

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis

BACKGROUND

Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.

AIM

To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.

DESIGN AND SETTING

Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.

METHOD

Changes in influenza-immunisation uptake for those in at-risk groups between 2003-2004 and 2006-2007 were measured, and variation in uptake examined using multilevel modelling.

RESULTS

Uptake rose from 67.9% in 2003-2004 to 71.4% in 2006-2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003-2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006-2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003-2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006-2007.

CONCLUSION

Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.

Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures?

BACKGROUND

Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs.

OBJECTIVE

To examine the association between PO location and P4P performance.

DESIGN

Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S.

PARTICIPANTS

160 POs participating in 2009.

MAIN MEASURES

We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use.

KEY RESULTS

The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001).

CONCLUSIONS

Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.

The reliability of medical group performance measurement in a single insurer's pay for performance program

BACKGROUND

Most public reporting and pay for performance (P4P) programs in the United States continue to be organized and implemented by single insurers. Adequate medical group-level reliability on clinical care process measures is possible in multistakeholder initiatives because patient samples can be pooled across payers. However, the extent to which reliable measurement is achievable in single insurer P4P initiatives remains unclear.

METHODS

This study uses 7 years (2001 to 2007) of patient-level clinical care process data from an insurer in Washington State involving 20 medical groups. Eight clinical care process measures were analyzed. We compared the medical group-level reliability and resulting sample size requirements for each of the 8 measures using unadjusted and adjusted binary mixed models. The relation of baseline intraclass correlation coefficients (ICCs) and medical group performance change over time was examined for each clinical care process measure.

RESULTS

Only 45% of all medical group measurements (group-years for all observations) had sufficient sample sizes to achieve reliable estimates of group performance. Measures with the largest deficiencies in patient samples per group included appropriate asthma treatment and low-density lipoprotein screening for patients with coronary artery disease. There was an inconsistent relationship between the size of baseline ICCs and medical group performance improvement over time.

CONCLUSIONS

Unreliable performance measurement is an important consequence of the prevailing organization and implementation of public reporting and P4P programs in the US. Multi-payer collaborations may be an important vehicle for ensuring reliable medical group performance measurement and comparisons on clinical care process measures.

Assessing the impact of innovative training of family physicians for the patient-centered medical home

BACKGROUND

New approaches to enhance access in primary care necessitate change in the model for residency education.

PURPOSE

To describe instrument design, development and testing, and data collection strategies for residency programs, continuity clinics, residents, and program graduates participating in the Preparing the Personal Physician for Practice (P(4)) project.

METHODS

We developed and pilot-tested surveys to assess demographic characteristics of residents, clinical and operational features of the continuity clinics and educational programs, and attitudes about and implementation status of Patient Centered Medical Home (PCMH) characteristics. Surveys were administered annually to P(4) residency programs since the project started in 2007. Descriptive statistics were used to profile data from the P(4) baseline year.

RESULTS

Most P(4) residents were non-Hispanic white women (60.7%), married or partnered, attended medical school in the United States and were the first physicians in their families to attend medical school. Nearly 85% of residency continuity clinics were family health centers, and about 8% were federally qualified health centers. The most likely PCMH features in continuity clinics were having an electronic health record and having fully secure remote access available; both of which were found in more than 50% of continuity clinics. Approximately one-half of continuity clinics used the electronic health record for safety projects, and nearly 60% used it for quality-improvement projects.

CONCLUSIONS

We created a collaborative evaluation model in all 14 P(4) residencies. Successful implementation of new surveys revealed important baseline features of residencies and residents that are pertinent to studying the effects of new training models for the PCMH.

Valuing improvement in value-based purchasing

BACKGROUND

Medicare will soon implement hospital value-based purchasing (VBP) using a scoring system that rewards both achievement (absolute performance) and improvement (performance increase over time). However, improvement is defined so as to give less credit to initial low performers than initial high performers. Because initial low performers are disproportionately hospitals in socioeconomically disadvantaged areas, these institutions stand to lose under Medicare's VBP proposal.

METHODS AND RESULTS

We developed an alternative improvement scale and applied it to hospital performance throughout the United States. By using 2005 to 2008 Medicare process measures for acute myocardial infarction (AMI) and heart failure (HF), we calculated hospital scores using Medicare's proposal and our alternative. Hospital performance scores were compared across 5 locational dimensions of socioeconomic disadvantage: poverty, unemployment, physician shortage, and high school and college graduation rates. Medicare's proposed scoring system yielded higher overall scores for the most locationally advantaged hospitals for 4 of 5 dimensions in AMI and 2 of 5 dimensions for HF. By using our alternative, differences in overall scores between hospitals in the most and least advantaged areas were attenuated, with locationally advantaged hospitals having higher overall scores for 3 of 5 dimensions for AMI and 1 of 5 dimensions for HF.

CONCLUSIONS

Using an alternative VBP formula that reflects the principle of "equal credit for equal improvement" resulted in a more equitable distribution of overall payment scores, which could allow hospitals in both socioeconomically advantaged and disadvantaged areas to succeed under VBP.

Association between quality of care and the sociodemographic composition of physicians' patient panels: a repeat cross-sectional analysis

BACKGROUND

Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.

OBJECTIVE

To test for associations between quality of care and the composition of a physician's patient panel.

DESIGN

Repeat cross-sectional analysis

PARTICIPANTS

Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000-2001 and 2004-2005

MAIN MEASURES

Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians' patient panels.

KEY RESULTS

Across eight quality measures, physicians' quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points.

CONCLUSIONS

In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians' quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.

Examining multiple sources of differential item functioning on the Clinician & Group CAHPS® survey

OBJECTIVE

To evaluate psychometric properties of a widely used patient experience survey.

DATA SOURCES

English-language responses to the Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS®) survey (n = 12,244) from a 2008 quality improvement initiative involving eight southern California medical groups.

METHODS

We used an iterative hybrid ordinal logistic regression/item response theory differential item functioning (DIF) algorithm to identify items with DIF related to patient sociodemographic characteristics, duration of the physician-patient relationship, number of physician visits, and self-rated physical and mental health. We accounted for all sources of DIF and determined its cumulative impact.

PRINCIPAL FINDINGS

The upper end of the CG-CAHPS® performance range is measured with low precision. With sensitive settings, some items were found to have DIF. However, overall DIF impact was negligible, as 0.14 percent of participants had salient DIF impact. Latinos who spoke predominantly English at home had the highest prevalence of salient DIF impact at 0.26 percent.

CONCLUSIONS

The CG-CAHPS® functions similarly across commercially insured respondents from diverse backgrounds. Consequently, previously documented racial and ethnic group differences likely reflect true differences rather than measurement bias. The impact of low precision at the upper end of the scale should be clarified.

Improving timely childhood immunizations through pay for performance in Medicaid-managed care

OBJECTIVE

To evaluate the impact of a "piece-rate" pay-for-performance (P4P) program aimed at rewarding up-to-date immunization delivery to 2-year-olds according to the recommended series.

DATA SOURCES/STUDY SETTING

Plan-level data from New York State's Quality Assurance Reporting Requirement and claims data from Hudson Health Plan for 2003-2007. In 2003 Hudson Health Plan, a not-for-profit Medicaid-focused managed care plan, introduced a U.S.$200 bonus payment for each fully immunized 2-year-old and provided administrative supports for identifying children who may need immunization. This represented a potential bonus of 15-25 percent above base reimbursement for eligible 2-year-olds.

STUDY DESIGN

Case-comparison and interrupted times series.

PRINCIPAL FINDINGS

Immunization rates within Hudson Health Plan rose at a significantly, albeit modestly, higher rate than the robust secular trend noted among comparison health plans. Supplementary analyses suggest that there was no significant change in preexisting disparities during the study period, and that children with chronic conditions have significantly greater odds of being fully immunized during the entire study period.

CONCLUSIONS

This study suggests that a piece-rate P4P program with appropriate administrative supports can be effective at improving childhood immunization rates.

Medicare readmissions policies and racial and ethnic health disparities: a cautionary tale

Beginning in 2009, the Centers for Medicare & Medicaid Services started publicly reporting hospital readmission rates as part of the Hospital Compare website. Hospitals will begin having payments reduced if their readmission rates are higher than expected starting in fiscal year 2013. Value-based purchasing initiatives including public reporting and pay-for-performance incentives have the potential to increase quality of care. There is concern, however, that hospitals providing service to minority communities may be disproportionately penalized as a result of these policies due to higher rates of readmissions among racial and ethnic minority groups. Using 2008 Medicare data, we assess the risk for readmission for minorities and discuss implications for minority-serving institutions.