Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care?

BACKGROUND Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality. PURPOSE To evaluate the effect of P4P remuneration targeting individual health care providers. DATA SOURCES MEDLINE, EMBASE, Cochrane Library, OpenSIGLE, Canadian Evaluation Society Unpublished Literature Bank, New York Academy of Medicine Library Grey Literature Collection, and reference lists were searched up until June 2012. STUDY SELECTION Two reviewers independently identified original research papers (randomized, controlled trials; interrupted time series; uncontrolled and controlled before-after studies; and cohort comparisons). DATA EXTRACTION Two reviewers independently extracted the data. DATA SYNTHESIS The literature search identified 4 randomized, controlled trials; 5 interrupted time series; 3 controlled before-after studies; 1 nonrandomized, controlled study; 15 uncontrolled before-after studies; and 2 uncontrolled cohort studies. The variation in study quality, target conditions, and reported outcomes precluded meta-analysis. Uncontrolled studies (15 before-after studies, 2 cohort comparisons) suggested that P4P improves quality of care, but higher-quality studies with contemporaneous controls failed to confirm these findings. Two of the 4 randomized trials were negative, and the 2 statistically significant trials reported small incremental improvements in vaccination rates over usual care (absolute differences, 8.4 and 7.8 percentage points). Of the 5 interrupted time series, 2 did not detect any improvements in processes of care or clinical outcomes after P4P implementation, 1 reported initial statistically significant improvements in guideline adherence that dissipated over time, and 2 reported statistically significant improvements in blood pressure control in patients with diabetes balanced against statistically significant declines in hemoglobin A1c control. LIMITATION Few methodologically robust studies compare P4P with other payment models for individual practitioners; most are small observational studies of variable quality. CONCLUSION The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans. PRIMARY FUNDING SOURCE None.

[1]  T. Walley,et al.  Do quality incentives change prescribing patterns in primary care? An observational study in Scotland. , 2008, Family practice.

[2]  H. Davies,et al.  Payment for performance in health care , 2008, BMJ : British Medical Journal.

[3]  Marla R. Miller,et al.  Increasing adherence to a community-based guideline for acute sinusitis through education, physician profiling, and financial incentives. , 2004, The American journal of managed care.

[4]  A. Legorreta,et al.  A Quality‐Driven Physician Compensation Model: Four‐Year Follow‐up Study , 2003, Journal for healthcare quality : official publication of the National Association for Healthcare Quality.

[5]  Shannon M E Murphy,et al.  Chronic care improvement in primary care: evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes. , 2010, Health services research.

[6]  R. Morrow,et al.  Improving physicians' preventive health care behavior through peer review and financial incentives. , 1995, Archives of family medicine.

[7]  Aziz Sheikh,et al.  Impact of the pay-for-performance contract and the management of hypertension in Scottish primary care: a 6-year population-based repeated cross-sectional study. , 2011, The British journal of general practice : the journal of the Royal College of General Practitioners.

[8]  W. J. Elliott,et al.  Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study , 2012 .

[9]  A. Majeed,et al.  Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis , 2012, The Annals of Family Medicine.

[10]  Colin Simpson,et al.  Effect of the UK Incentive–Based Contract on the Management of Patients With Stroke in Primary Care , 2006, Stroke.

[11]  S. Maisey,et al.  Effects of payment for performance in primary care: Qualitative interview study , 2008, Journal of health services research & policy.

[12]  Robert Fleetcroft,et al.  Quality of clinical primary care and targeted incentive payments: an observational study. , 2007, The British journal of general practice : the journal of the Royal College of General Practitioners.

[13]  Vasa Curcin,et al.  Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care , 2011, Canadian Medical Association Journal.

[14]  Evangelos Kontopantelis,et al.  Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework , 2011, BMJ : British Medical Journal.

[15]  Gary J. Young,et al.  Effects of Paying Physicians Based on their Relative Performance for Quality , 2007, Journal of General Internal Medicine.

[16]  J. Lemkau,et al.  Enhancing mammography referral in primary care. , 1997, Preventive medicine.

[17]  A. Kopp,et al.  The Relationship Between Financial Incentives and Quality of Diabetes Care in Ontario, Canada , 2012, Diabetes Care.

[18]  Sheila Roman,et al.  Public reporting and pay for performance in hospital quality improvement. , 2007, The New England journal of medicine.

[19]  M. Higgins,et al.  Improving anesthesiologist performance through profiling and incentives. , 2004, Journal of clinical anesthesia.

[20]  B. Sibbald,et al.  Effects of pay for performance on the quality of primary care in England. , 2009, The New England journal of medicine.

[21]  B. Saver,et al.  Effect of Financial Incentives on Improvement in Medical Quality Indicators for Primary Care , 2010, The Journal of the American Board of Family Medicine.

[22]  F M LaForce,et al.  Performance-based physician reimbursement and influenza immunization rates in the elderly. The Primary-Care Physicians of Monroe County. , 1998, American journal of preventive medicine.

[23]  Craig R Ramsay,et al.  INTERRUPTED TIME SERIES DESIGNS IN HEALTH TECHNOLOGY ASSESSMENT: LESSONS FROM TWO SYSTEMATIC REVIEWS OF BEHAVIOR CHANGE STRATEGIES , 2003, International Journal of Technology Assessment in Health Care.

[24]  Manuel C. Pontes.  Agency theory: A framework for analyzing physician services , 1995, Health care management review.

[25]  B. Guthrie,et al.  Continuity of care matters , 2008, BMJ : British Medical Journal.

[26]  J. Wike,et al.  The Influence of Year-End Bonuses on Colorectal Cancer Screening , 2003, The American journal of managed care.

[27]  R. Hamblin.  Regulation, measurements and incentives. The experience in the US and UK: does context matter? , 2008, The journal of the Royal Society for the Promotion of Health.

[28]  A. Majeed,et al.  Impact of a pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes , 2007, Canadian Medical Association Journal.

[29]  J. Higgins,et al.  Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0. The Cochrane Collaboration , 2013 .

[30]  K. Lefevre,et al.  Introduction of a new incentive and target‐based contract for family physicians in the UK: good for older patients with diabetes but less good for women? , 2008, Diabetic medicine : a journal of the British Diabetic Association.

[31]  P. Kory,et al.  Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial. , 2001, Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association.

[32]  Nancy Dean Beaulieu,et al.  Putting smart money to work for quality improvement. , 2005, Health services research.

[33]  R. Daniels,et al.  Primary care , 1998, BMJ : British Medical Journal.

[34]  Arleen F. Brown,et al.  Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care? , 2006, Health services research.

[35]  Ming Tai-Seale,et al.  Association between physician compensation methods and delivery of guideline-concordant STD care: is there a link? , 2005, The American journal of managed care.

[36]  Michele Tarsilla.  Cochrane Handbook for Systematic Reviews of Interventions , 2010, Journal of MultiDisciplinary Evaluation.

[37]  M. Rosenthal,et al.  Early experience with pay-for-performance: from concept to practice. , 2005, JAMA.

[38]  E John Orav,et al.  The long-term effect of premier pay for performance on patient outcomes. , 2012, The New England journal of medicine.

[39]  Tim Coleman,et al.  Impact of contractual financial incentives on the ascertainment and management of smoking in primary care. , 2007, Addiction.

[40]  A. Scott,et al.  The effect of financial incentives on the quality of health care provided by primary care physicians. , 2011, The Cochrane database of systematic reviews.

[41]  Colin R Simpson,et al.  The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care. , 2007, Family practice.

[42]  J. Kralewski,et al.  The effects of medical group practice and physician payment methods on costs of care. , 2000, Health services research.

[43]  Laura Petersen,et al.  Does Pay-for-Performance Improve the Quality of Health Care? , 2006, Annals of Internal Medicine.

[44]  H. Brenner,et al.  Effects of practitioner education, practitioner payment and reimbursement of patients’ drug costs on smoking cessation in primary care: a cluster randomised trial , 2007, Tobacco Control.