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Navathe AS, Volpp KG, Bond AM, Linn KA, Caldarella KL, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye EE, Bernheim SM, Oshima Lee E, Mugiishi M, Endo KT, Yoshimoto J, Emanuel EJ. Assessing The Effectiveness Of Peer Comparisons As A Way To Improve Health Care Quality. Health Aff (Millwood) 2020; 39:852-861. [DOI: 10.1377/hlthaff.2019.01061] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Amol S. Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs (VA) Medical Center; and an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
| | - Kevin G. Volpp
- Kevin G. Volpp is a professor of medicine in the Department of Medicine at the Perelman School of Medicine and of health care management at the Wharton School, vice chair for health policy in the Department of Medical Ethics and Health Policy, and director of the Center for Health Incentives and Behavioral Economics, all at the University of Pennsylvania, and a staff physician at the Corporal Michael J. Crescenz VA Medical Center
| | - Amelia M. Bond
- Amelia M. Bond is an assistant professor of health care policy and research at Weill Cornell Medical College, in New York City
| | - Kristin A. Linn
- Kristin A. Linn is an assistant professor of biostatistics in the Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Kristen L. Caldarella
- Kristen L. Caldarella is a project manager in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Andrea B. Troxel
- Andrea B. Troxel is director of the Division of Biostatistics, New York University School of Medicine, in New York City
| | - Jingsan Zhu
- Jingsan Zhu is associate director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Lin Yang
- Lin Yang is a programmer analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Shireen E. Matloubieh
- Shireen E. Matloubieh is a research coordinator in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Elizabeth E. Drye
- Elizabeth E. Drye is a research scientist in the Department of Pediatrics, Yale University School of Medicine, in New Haven, Connecticut
| | - Susannah M. Bernheim
- Susannah M. Bernheim is director of quality measurement at the Center for Outcomes Research and Evaluation at Yale–New Haven Hospital and an assistant clinical professor in the Department of Internal Medicine at Yale University School of Medicine
| | - Emily Oshima Lee
- Emily Oshima Lee is assistant vice president of health strategy at the Hawaii Medical Services Association (HMSA), in Honolulu
| | | | - Kimberly Takata Endo
- Kimberly Takata Endo is a health strategist in the Department of Payment Transformation, HMSA
| | - Justin Yoshimoto
- Justin Yoshimoto is a health strategist in the Department of Payment Transformation, HMSA
| | - Ezekiel J. Emanuel
- Ezekiel J. Emanuel is the Diane V. S. Levy and Robert M. Levy University Professor, chair of the Department of Medical Ethics and Health Policy, and vice provost for global initiatives, all at the University of Pennsylvania
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Navathe AS, Volpp KG, Caldarella KL, Bond A, Troxel AB, Zhu J, Matloubieh S, Lyon Z, Mishra A, Sacks L, Nelson C, Patel P, Shea J, Calcagno D, Vittore S, Sokol K, Weng K, McDowald N, Crawford P, Small D, Emanuel EJ. Effect of Financial Bonus Size, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Clinical Trial and Cohort Study. JAMA Netw Open 2019; 2:e187950. [PMID: 30735234 PMCID: PMC6484616 DOI: 10.1001/jamanetworkopen.2018.7950] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/11/2018] [Indexed: 12/01/2022] Open
Abstract
Importance Despite limited effectiveness of pay-for-performance (P4P), payers continue to expand P4P nationally. Objective To test whether increasing bonus size or adding the behavioral economic principles of increased social pressure (ISP) or loss aversion (LA) improves the effectiveness of P4P. Design, Setting, and Participants Parallel studies conducted from January 1 to December 31, 2016, consisted of a randomized clinical trial with patients cluster-randomized by practice site to an active control group (larger bonus size [LBS] only) or to groups with 1 of 2 behavioral economic interventions added and a cohort study comparing changes in outcomes among patients of physicians receiving an LBS with outcomes in propensity-matched physicians not receiving an LBS. A total of 8118 patients attributed to 66 physicians with 1 of 5 chronic conditions were treated at Advocate HealthCare, an integrated health system in Illinois. Data were analyzed using intention to treat and multiple imputation from February 1, 2017, through May 31, 2018. Interventions Physician participants received an LBS increased by a mean of $3355 per physician (LBS-only group); prefunded incentives to elicit LA and an LBS; or increasing proportion of a P4P bonus determined by group performance from 30% to 50% (ISP) and an LBS. Main Outcomes and Measures The proportion of 20 evidence-based quality measures achieved at the patient level. Results A total of 86 physicians were eligible for the randomized trial. Of these, 32 were excluded because they did not have unique attributed patients. Fifty-four physicians were randomly assigned to 1 of 3 groups, and 33 physicians (54.5% male; mean [SD] age, 57 [10] years) and 3747 patients (63.6% female; mean [SD] age, 64 [18] years) were included in the final analysis. Nine physicians and 864 patients were randomized to the LBS-only group, 13 physicians and 1496 patients to the LBS plus ISP group, and 11 physicians and 1387 patients to the LBS plus LA group. Physician characteristics did not differ significantly by arm, such as mean (SD) physician age ranging from 56 (9) to 59 (9) years, and sex (6 [46.2%] to 6 [66.7%] male). No differences were found between the LBS-only and the intervention groups (adjusted odds ratio [aOR] for LBS plus LA vs LBS-only, 0.86 [95% CI, 0.65-1.15; P = .31]; aOR for LBS plus ISP vs LBS-only, 0.95 [95% CI, 0.64-1.42; P = .81]; and aOR for LBS plus ISP vs LBS plus LA, 1.10 [95% CI, 0.75-1.61; P = .62]). Increased bonus size was associated with a greater increase in evidence-based care relative to the comparison group (risk-standardized absolute difference-in-differences, 3.2 percentage points; 95% CI, 1.9-4.5 percentage points; P < .001). Conclusions and Relevance Increased bonus size was associated with significantly improved quality of care relative to a comparison group. Adding ISP and opportunities for LA did not improve quality. Trial Registration ClinicalTrials.gov Identifier: NCT02634879.
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Affiliation(s)
- Amol S. Navathe
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kristen L. Caldarella
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amelia Bond
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
- Department of Health Care Management, Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Andrea B. Troxel
- Department of Population Health, School of Medicine, New York University, New York, New York
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shireen Matloubieh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zoe Lyon
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Akriti Mishra
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lee Sacks
- Advocate Physician Partners, Downers Grove, Illinois
| | - Carrie Nelson
- Advocate Physician Partners, Downers Grove, Illinois
| | - Pankaj Patel
- Advocate Physician Partners, Downers Grove, Illinois
| | - Judy Shea
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Don Calcagno
- Advocate Physician Partners, Downers Grove, Illinois
| | | | - Kara Sokol
- Advocate Physician Partners, Downers Grove, Illinois
| | - Kevin Weng
- Advocate Physician Partners, Downers Grove, Illinois
| | | | - Paul Crawford
- Advocate Physician Partners, Downers Grove, Illinois
| | - Dylan Small
- Department of Health Care Management, Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
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