Key Articles

Below is compilation of all articles the authors' of this website have designated as most impactful and significant. Articles are organized by sections of the website and arranged with older articles listed first. Each section of the website also has a list of relevant key articles within it.

 

 

Overview

(326) Greene SE, Nash DB. Pay for Performance: An Overview of the Literature. American Journal of Medical Quality. 2009: 24(2) 140-163.

PMID: 18984907

Summary:

  • Extensive overview of all literature regarding P4P
  • In depth summaries of key financial incentive trials throughout the world.
  • Reviews physician perception of P4P.
  • Touches on cost analysis of P4P, support for P4P, and arguments against P4P.

Significance to Literature:

Extensive and in-depth article covering most current literature available as of 2009 regarding P4P. 

 

(345) Khullar D et al. How 10 Leading Health Systems Pay Their Doctors. Healthcare. 2015 Jun;3(2):60-2. doi: 10.1016/j.hjdsi.2014.11.004. Epub 2014 Dec 16.

PMID: 26179724

Summary:

  • Interviews with senior executives at ten leading health systems including: Kaiser, Mayo, Intermountain, Geisinger, Cleveland Clinic.
  • Analysis of healthcare organizations utilization of performance-based compensation
  • Performance-based pay more prevalent in primary care than in subspecialties
  • Most have less than 10% of pay tied to performance

Significance to Literature:

Models with many metrics and low at-risk compensation for each metric are often ineffective at reaching goals

 

(348) Martin W. A Look at Physician Compensation Models. Physician Leadership Journal. 2015 Jul-Aug;2(4):64-7.

PMID: 26285399

Summary:

  • Summarizes incentive structures and effect on quality of patient care for ten models of physician compensation
  • Compensation models included are fee-for-service, fee-for-value, pay-for-performance, salary, capitation, bundled payment, accountable care organization, concierge, direct pay contracting, and volunteering.

Significance to Literature:

An overview of how physician payment structure plays a vital role in the overuse, underuse, and misuse of healthcare resources

 

(383) Allen T, Mason T, Whittaker W. Impacts of pay for performance on the quality of primary care. Risk Manag Healthc Policy. 2014 Jul 2;7:113-20. doi: 10.2147/RMHP.S46423. eCollection 2014.

PMID: 25061341

Summary:

  • General overview of P4P theory and applications and their impact on the quality of primary care in the UK
  • Adoption of P4P is increasing worldwide despite ambiguous evidence for its efficacy and continued difficulty with the evaluation of programs
  • The authors outline a list of potential unintended consequences including: measure fixation, short-termism, manipulation of measures, gaming, etc.
  • Discussion of the United Kingdom’s ten-year-old Quality and Outcomes Framework (QOF) program, the largest P4P example in primary care
  • Performance initially improved in a stepwise fashion for incentivized areas of quality, but quickly regressed to pre-QOF rates of improvement after the first year of implementation. (i.e. Outcomes were slowly improving prior to QOF. Outcomes improved quickly during the initial QOF year. Thereafter, outcomes continued to improve, but as slowly as they had in the pre-QOF era)

Significance to Literature:

P4P evidence is mixed and difficult to analyze. New schemes must be designed from the beginning to better allow evaluation, including control and treatment groups coupled with before and after data. Evidence for rapid improvements in performance were observed for only the first year of QOF.

 

 

Program Design and Implementation

(169) Brantes FD, Wickland PS, Williams JP. The Value of Ambulatory Care Measures: A review of Clinical and Financial Impact from an Employer/Payer Perspective. American Journal of Managed Care. 2008:14(6) 360-368.

PMID: 18554074

Summary:

  • Economic and clinical literature review of 62 quality metrics used in primary care P4P.
  • Of the top 20 metrics based on clinical and economic support, 16 were found to be cost-saving in the short-term.
  • Many primary care measures may have little clinical evidence beyond expert opinion.

Significance to Literature:

Systematic clinical and economic evaluation of 62 ambulatory care measures.

 

(262) Pay-For-Performance. AAFP position paper. August 29, 2005.

Link: http://www.aafp.org/online/en/home/policy/policies/p/payforperformance.html

Summary:

  • Summarizes the American Academy of Family Physicians (AAFP) stance on experimentation of physician payment methodologies, specifically in designing P4P programs.
  • The central purpose of all P4P programs must be to improve the quality of patient care and clinical outcomes.
  • Lists 14 guidelines for the development and implementation of P4P programs that the AAFP will support.

Significance to Literature:

AAFP position paper provides detailed criteria for P4P programs they would support.

 

(316) Foels T, Hewner S. Integrating Pay for Performance with Educational Strategies to Improve Diabetes Care. Population Health Management. 2009: 12 121-129.

PMID: 19534576

Summary:

  • Study aimed to assess improvement of diabetes care after P4P and inspirational support implementation
  • Assessed nine processed measures over 4.5 years, 
  • Results suggested that inspirational support and P4P produced an accelerated performance trajectory.
  • "Once providers are aware of gaps in their performance, they often are extremely interested in strategies that will help close the gaps."

Significance to Literature:

Positive P4P outcome with emphasis on teaching the clinician how to provide better care.

 

(345) Khullar D et al. How 10 Leading Health Systems Pay Their Doctors. Healthcare. 2015 Jun;3(2):60-2. doi: 10.1016/j.hjdsi.2014.11.004. Epub 2014 Dec 16.

PMID: 26179724

Summary:

  • Interviews with senior executives at ten leading health systems including: Kaiser, Mayo, Intermountain, Geisinger, Cleveland Clinic.
  • Analysis of healthcare organizations utilization of performance-based compensation
  • Performance-based pay more prevalent in primary care than in subspecialties
  • Most have less than 10% of pay tied to performance

Significance to Literature:

Models with many metrics and low at-risk compensation for each metric are often ineffective at reaching goals

 

(351) Greene J, Kurtzman ET, Hibbard JH, Overton V. Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians’ Perceptions. Annals of Family Medicine. 2015;13(3):235-241. doi:10.1370/afm.1779.

PMID: 25964401

Summary:

  • Examination of primary care provider perceptions of clinic-level quality incentives versus individual-level incentives.
  • Both in-depth interviews and online surveys were used to assess advantages and disadvantages of clinic vs individual level incentives.

Significance to Literature:

Most (73%) clinicians stated both clinic and individual-level incentives should be used in order to promote collaboration while still recognizing individual performance.

 

(383) Allen T, Mason T, Whittaker W. Impacts of pay for performance on the quality of primary care. Risk Manag Healthc Policy. 2014 Jul 2;7:113-20. doi: 10.2147/RMHP.S46423. eCollection 2014.

PMID: 25061341

Summary:

  • General overview of P4P theory and applications and their impact on the quality of primary care in the UK
  • Adoption of P4P is increasing worldwide despite ambiguous evidence for its efficacy and continued difficulty with the evaluation of programs
  • The authors outline a list of potential unintended consequences including: measure fixation, short-termism, manipulation of measures, gaming, etc.
  • Discussion of the United Kingdom’s ten-year-old Quality and Outcomes Framework (QOF) program, the largest P4P example in primary care
  • Performance initially improved in a stepwise fashion for incentivized areas of quality, but quickly regressed to pre-QOF rates of improvement after the first year of implementation. (i.e. Outcomes were slowly improving prior to QOF. Outcomes improved quickly during the initial QOF year. Thereafter, outcomes continued to improve, but as slowly as they had in the pre-QOF era)

Significance to Literature:

P4P evidence is mixed and difficult to analyze. New schemes must be designed from the beginning to better allow evaluation, including control and treatment groups coupled with before and after data. Evidence for rapid improvements in performance were observed for only the first year of QOF.

 

(408) Asch et al. Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial. JAMA. 2015 Nov 10;314(18):1926-35. doi: 10.1001/jama.2015.14850.

PMID: 26547464

Summary:

  • Multicenter cluster randomized clinical trial comparing the effect of physician financial incentives, patient financial incentives, shared physician and patient incentives, and no incentives on reducing levels of low-density lipoprotein cholesterol (LDL-C) in high cardiovascular risk patients
  • Patients were deemed eligible based on Framingham-Risk Scores, LDL-C levels, and presence of coronary artery disease
  • Primary care physicians and patients were randomly assigned to each group. Physicians were each eligible to receive up to $1024 annually per patient and patients could receive up to the same amount via entrance into daily lotteries based on medication adherence
  • Only patients in the shared physician/patient incentive group achieved significantly reduced LDL-C levels compared to the control group after 12-month intervention
  • Shared incentive average was 126.4 mg/dl compared to 136.4 mg/dl in the control group

Significance to Literature:

Promising evidence for physician and patient shared incentives in P4P primary schemes and an indication for further research

 

(434) Henkel RJ, Maryland PA. The Risks and Rewards of Value-Based Reimbursement. Front Health Serv Manage. 2015 Winter;32(2):3-16.

PMID: 26817266

Summary:

  • Lessons from leaders of the largest not-for-profit healthcare system in the United States, Ascension Health, on how to engage patients and providers in creating new ways to better coordinate care in the shift to value-based payment models
  • Ascension itself is committed to keeping the Quadruple Aim as the goal for this transition
  • Review of value-based models to choose from, including P4P, shared savings, bundled payments, shared risk, global capitation, and provider-sponsored health plans
  • Analysis of options for healthcare systems and providers should include:
    • Evaluation of market readiness
    • Preparedness to invest in resources to improve transition and care management
    • Recognition that cost-structure adjustments will need to be made as inpatient volumes decline
  • Some healthcare systems are considering becoming their own payers to accommodate this change

Significance to Literature:

Recommendations from executives of Ascension Health on how to best facilitate the volume-to-value transformation

 

 

Programs

United States

(353) Kahn CN 3rd et al. Assessing Medicare's hospital pay-for-performance programs and whether they are achieving their goals. Health Affairs. 2015 Aug;34(8):1281-8. doi: 10.1377/hlthaff.2015.0158.

PMID: 26240240

Summary:

  • An increasing amount of Medicare hospital payments are tied to one of Medicare’s three pay-for-performance programs (Hospital Readmission Reduction Program, Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program)
  • In 2015, four out of five eligible hospitals will be penalized by one of the three programs and one out of three teaching hospitals will be penalized by all three programs

Significance to Literature:

Reevaluation of program components may be necessary. Authors propose ensuring risk-adjustment appropriateness, minimizing program overlap and differences in scoring, increasing incentive to improve even if below target levels, and considering alternatives to the current three programs.

 

 

(427) Mulvany C. MACRA: the Medicare physician payment system continues to evolve. Healthc Financ Manage. 2016 Feb;70(2):32-5.

PMID: 26999974

Summary:

  • Summary of what is contained in MACRA, how it affects physicians, and recommendations for providers before its implementation in 2019
  • Starting in 2019 physician and physician extenders will need to participate in the Merit-Based Incentive System (MIPS) or an Alternative Payment Model (APM)
  • Congress offers two financial incentives for professionals to participate in qualifying APMs, including a 0.5% increased Medicare annual update compared to MIPS beginning in 2026 and a 5% annual bonus payment from 2019-2024
  • To qualify, APMs must:
    • Require use of certified EHR technology
    • Link payment to quality measures similar to those in the MIPS category
    • Require participation in the APM to bear “more than nominal financial risk”
  • The wording of MACRA leaves providers with numerous uncertainties due to the discretion CMS has in how the law is actually implemented. Providers should:
    • Monitor the regulatory process related to MACRA closely
    • Develop a strategic and financial framework for evaluating whether to default to MIPS or seek participation in an APM
    • Begin/continue experimenting with payments that transfer some degree of risk to providers

Significance to Literature:

Summary of the implications of MACRA and how to prepare for its implementation in 2019


 

(428) Demehin A, Jackson M. Dissecting New Medicare Physician Pay. Trustee. 2016 Mar;69(3):17-9, 1.

PMID: 27125119

Summary:

  • In addition to the implementation of a predictable Medicare fee schedule, MACRA aims to move payment away from fee-for-service and towards a payment system tied to patient outcomes and population health
  • CMS seeks to accomplish this by encouraging participation in either the MACRA-created default Medicare payment scheme called the Merit-Based Incentive System (MIPS) or an alternative payment models (APM)
  • For its implementation in 2019, the law will only apply to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists
  • Expansion to other nonphysician professionals who bill under the physician fee schedule may occur in 2021,
  • Physician composite scores of 0-100 points based on performance in four categories:
    • Quality
    • Resource use
    • Clinical practice improvement
    • Meaningful use of EHR technology
  • Each year CMS will establish a performance threshold:
    • Physicians at or above the threshold will receive no financial penalty or a bonus
    • Physicians below the threshold will receive a linear sliding-scale negative payment adjustment based on how far below the threshold they reside
    • Because the payment system is budget neutral, CMS cannot pay out more incentive than they withhold in penalties
  • Hospitals will be directly and indirectly affected by the new payment system:
    • Hospitals that employ physicians will bear the burden of implementation and compliance costs, as well as financial withholdings due to poor performance
    • More physicians may seek employment or contractual relationships with hospitals to achieve stability and potentially minimize their financial risk
    • Hospitals will experience pressure to participate in APMs

Significance to Literature:

Summary of key aspects of MACRA with an added focus on the implications on hospitals

 

 

International

(59) Mannion, R, Davies H. Payment for performance in health care. BMJ. 2008: 336 306-308.

PMID: 18258966

Summary:

  • Financial reward is a key factor in the success of P4P.
  • Article addresses the good vs. bad of both high and low financial reward.
  • Evaluation of P4P has not been able to keep up with implementation.
  • Preliminary evaluations of the quality and outcomes framework show benefits and adverse consequences.

Significance to Literature:

Summary of P4P in the United Kingdom in February 2008.

 

(162) Campbell SM, McDonald R, Lester H. The Experience of Pay for Performance in English Family Practice: A Qualitative Study. Annals of Family Medicine. 2008: 6(3) 228-234.

PMID: 18474885

Summary:

  • Interviewed 20 nurses and 21 family doctors across England to explore beliefs and concerns about changes to service as a result of P4P between 2004-2007.
  • Many doctors and nurses acknowledged that nurses have become the primary provider of health care for patients with chronic disease, however most P4P reimbursements go to doctors.
  • The QOF achieved objectives:
    • Improved disease specific processes of patient care
    • Increased primary care physician income
    • Improved data capture
    • Lists unintended consequences including:
    • Dual QOF-patient agenda within consultations
    • Potential deskilling of doctors
    • Decline in doctor/patient continuity of care
    • Resentment by team member not benefiting financially
    • Concerns about an ongoing culture of performance monitoring

Significance to Literature:

British family doctors and nurses surveyed believe that despite benefits, P4P negatively affects relationships between doctors, nurses, and patients.

 

(164) Doran T. Lessons from Early Experience with Pay for Performance. Journal Disease Management and Health Outcomes. 2008: 16(2) 69-77.

Link: http://link.springer.com/article/10.2165%2F00115677-200816020-00001

Summary:

  • Evidence of long-term benefits and harms of the UK’s QOF P4P schemes is beginning to emerge, better health outcomes must be observed to continue P4P.
  • Early reports from the UK are encouraging.
  • Author lists 10 characteristics of successful P4P schemes, and discusses 3 risks associated with P4P that must be examined.

Significance to Literature:

Provides insights, based on data from 2004-2007, about successful and unsuccessful elements of the United Kingdom’s QOF P4P program.

 

(186) Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of Patients from Pay-for-Performance Targets by English Physicians. NEJM. 2008: 359(3) 274-284.

PMID: 18635432

Summary:

  • Article first discusses the three approaches to avoiding inappropriate treatment of patients when a quality indicator does not apply when other considerations must take precedence:
    • Risk-adjust
    • Maximum achievement thresholds
    • Exception reporting
  • Analysis of data from exception reporting in the UK, including financial gain analysis, and the effect of the characteristics of patients and medical practices.
  • The median rate of exceptions in 2005-2006 was 5.3%
  • Authors conclude that exception reporting has brought substantial benefits to P4P in the UK, and there is little evidence of gaming the system.
  • Exceptions accounted for about 1.5% of the cost of the P4P program in the UK.
  • Discusses the arguments for and against exception reporting.

Significance to Literature:

Exclusion of patients is necessary in P4P, this demonstrates a successful attempt to do so.

 

 

P4P by Specialty

(168) Glickman SW, Schulman KA, Peterson ED, Hocker MB, Cairns CB. Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine. Annals of Emergency Medicine. 2008: 51(5) 622-631.

PMID: 18358566

Summary:

  • Article reviews the 9 emergency care performance metrics and grades them based on the American College of Cardiology and American Heart Association criteria for selection of performance measures to improve quality.
  • 5 of the 9 emergency measures meet all four of the criteria.
  • Authors suggest 2 new performance measures that should be used.
  • Quality improvement initiatives in emergency medicine would benefit greatly from large research networks.

Significance to Literature:

Overview of the P4P measures in Emergency medicine.

 

(282) Murphy KM, Nash DB. Nonprimary Care Physicians’ Views on Office-Based Quality Incentive and Improvement Programs. American Journal of Medical Quality. 2008: 23(6) 427-439.

PMID: 19001100

Summary:

  • "While 41% of the total number of annual physician office visits are made to nonprimary care physicians, accounting for 70-80% national healthcare expenditures for all physicians services, historically the most common P4P programs are limited to primary care services." 
  • Authors summarize survey of physician attitudes towards quality incentive programs. For example, physicians traditionally favor payment schemes that avert risk.
  • 42% of respondents agreed or strongly agreed that quality incentive programs offer an opportunity to differentiate quality performance.
  • Physicians with fewer years of experience tended to favor quality improvement initiatives.
  • Studies examining the effect of financial incentives of physicians behavior in order to change phsyicians behavior, an incentive must account for 10% of the physician's annual income."
  • "Nonprimary care physicians had the most unfavorable views of public disclosure of quality performance."
  • Most physicians viewed current implementation of P4P as a means to decrease physician reimbursement.
  • Physicians who received information from their specialty society on clinical performance measures were more likely to view quality incentives more favorably.

Significance to Literature:

Nonprimary care physicians attitudes towards P4P differ signficantly from those of primary care physicians who currently participate in more extensively in P4P programs.

 

Data and Outcomes

(425) Ryan et al. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet. 2016 Jul 16;388(10041):268-274. doi: 10.1016/S0140-6736(16)00276-2. Epub 2016 May 17.

PMID: 27207746

Summary:

  • The United Kingdom’s (UK) Quality and Outcomes Framework (QOF), introduced in 2004, is the world’s largest primary care P4P program
  • Population-level mortality statistics from 1994-2010 for the UK and other high-income countries were assessed
  • Primary outcome was mortality per 100,000 population for “a composite outcome of disease areas that were targeted by the QOF from the beginning of the program”
  • Secondary outcomes included mortality for ischemic heart disease, cancer, and a composite of all causes of death not included in the primary outcome
  • No significant association with improved population mortality was found for any assessed disease area, both those targeted and not targeted by the QOF

Significance to Literature:

Results indicates that the viability of P4P to improve population mortality is questionable, and the comparison of the cost-effectiveness of P4P to other health system interventions is necessary

 

United States

(353) Kahn CN 3rd et al. Assessing Medicare's hospital pay-for-performance programs and whether they are achieving their goals. Health Affairs. 2015 Aug;34(8):1281-8. doi: 10.1377/hlthaff.2015.0158.

PMID: 26240240

Summary:

  • An increasing amount of Medicare hospital payments are tied to one of Medicare’s three pay-for-performance programs (Hospital Readmission Reduction Program, Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program)
  • In 2015, four out of five eligible hospitals will be penalized by one of the three programs and one out of three teaching hospitals will be penalized by all three programs

Significance to Literature:

Reevaluation of program components may be necessary. Authors propose ensuring risk-adjustment appropriateness, minimizing program overlap and differences in scoring, increasing incentive to improve even if below target levels, and considering alternatives to the current three programs.

 

(374) Rosenthal et al. Pay for Performance in Medicaid: Evidence from Three Natural Experiments. Health Serv Res. 2015 Dec 27. doi: 10.1111/1475-6773.12426. [Epub ahead of print]

PMID: 26708000

Summary:

Examination of the P4P effect on quality and utilization of care in Medicaid between P4P intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states (Florida, Wisconsin, Georgia)

  • All three programs focused on physician incentives as opposed to hospitals or managed care organizations, but each utilized a distinct model of incentives:
  • Medical home structural incentive and shared savings model (Alabama)
  • Diabetes program which rewards providers based on an “all-or-none” measure and payment for intermediate health outcomes as opposed to solely process measures (Minnesota)
  • Rewarding collaboration for disease management of chronically ill patients based on process measures (Pennsylvania)
  • Results were as follows:
    • Reduction of ambulatory visits in Pennsylvania compared with Florida
    • Decrease in hospital admissions in Minnesota compared to Wisconsin
    • Slight decline in hospital admissions but an increase in ambulatory visits in Alabama compared to Georgia
    • Little improvement in process quality measures, and modest reductions in inpatient use in Minnesota and Alabama

Significance to Literature:

There was no evidence for more quality improvement In States with P4P Medicaid programs as compared to matched States with no P4P Medicaid programs. However, a limitation we noted (as authors of this website and professionals in Minnesota) was that the Minnesota/Wisconsin comparison used percentage of diabetics receiving A1c and LDL tests, whereas Minnesota’s P4P program rewarded for A1c outcome <7 and LDL <100.  

There were significant changes in utilization patterns.

States on the forefront of P4P implementation should inform future program design as more states move to performance and quality-based payment.

 

(408) Asch et al. Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial. JAMA. 2015 Nov 10;314(18):1926-35. doi: 10.1001/jama.2015.14850.

PMID: 26547464

Summary:

  • Multicenter cluster randomized clinical trial comparing the effect of physician financial incentives, patient financial incentives, shared physician and patient incentives, and no incentives on reducing levels of low-density lipoprotein cholesterol (LDL-C) in high cardiovascular risk patients
  • Patients were deemed eligible based on Framingham-Risk Scores, LDL-C levels, and presence of coronary artery disease
  • Primary care physicians and patients were randomly assigned to each group. Physicians were each eligible to receive up to $1024 annually per patient and patients could receive up to the same amount via entrance into daily lotteries based on medication adherence
  • Only patients in the shared physician/patient incentive group achieved significantly reduced LDL-C levels compared to the control group after 12-month intervention
  • Shared incentive average was 126.4 mg/dl compared to 136.4 mg/dl in the control group

Significance to Literature:

Promising evidence for physician and patient shared incentives in P4P primary schemes and an indication for further research

 

International

(320) Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of Pay for Performance on Quality of Primary Care in England. NEJM. 361(4) 368-378.

PMID: 19625717

Summary:

  • Time-series analysis of 42 family practices in the United Kingdom of the clinical quality scores pre- (1998 and 2003) and post- (2005 and 2007) P4P (QOF) implementation in 2004.
  • Measured clinical care in coronary heart disease, asthma, and diabetes. Measured patients' perceptions in communication with physicians, access to care, and continuity of care.
  • Clinical quality of care increased for diabetes and asthma from 2003 to 2005, but by 2007 improvement had slowed. While improvement for heart disease was marginal from 2003 to 2005, and similar in 2007 compared to 2005.
  • Patients' perceptions of care regarding access and interpersonal aspects remained similar throughout,while continuity of care decreased immediately following P4P implementation, but remained steady at a reduced level in 2007.
  • Structure of P4P program did not reward for further improvement once targets had been achieved.
  • Meanwhile, two non-incentivized quality of care measures decreased in both asthma and heart disease treatment.

Significance to Literature:

Once quality targets were met, quality improvement was slowed, while quality of care for non-incentivized conditions decreased.

 

(369) Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf. 2015 Dec 30. pii: bmjqs-2015-005003. doi: 10.1136/bmjqs-2015-005003. [Epub ahead of print]

PMID: 26717988

Summary:

  • United Kingdom’s pay-for-performance program, Quality and Outcomes Framework, allows for general practitioners to exclude patients from quality calculations without financial penalty
  • This practice, known as exception reporting, was designed to allow providers to use clinical judgement to exempt patients from evidence-based guidelines when not applicable and protect physicians from patient non-compliance, but has been controversial.
  • Notable points include:
    • 1% of practices were responsible for 15% of all exception reporting
    • Higher target quality markers are associated with higher rates of exception reporting
    • Increased exception reporting for complex patients with multiple comorbidities
    • Patients from lower socioeconomic areas are more likely to be exception reported
    • Exception reporting is associated with increased risk of death for patients

Significance to Literature:

Physicians exception reported uncommonly yet more work needs to be done to better understand if and when providers’ decisions to circumvent evidence-based guidelines is appropriate.

 

 

Additional Performance-Based Programs

(64) Pham H, et al. Care Patterns in Medicare and Their Implications for Pay for Performance. NEJM. 2007: 356(11) 1130-1139.

PMID: 17360991

Summary:

  • Article seeks to answer what the role is for Primary Care Physicians amongst Medicare patients under P4P.
  • 1/3 patients change PCP every year, and many see multiple providers, making it very difficult assign responsibility for patient care.
  • Dispersion of patient care may limit the effectiveness of P4P.

Significance to Literature:

Properly assigning responsibility for patient care will be a limiting factor for the effectiveness of P4P.

 

(143) Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine. 2008: 148(2) 111-123.

PMID: 18195336

Summary:

  • 45 articles were reviewed that evaluate the impact of public reported performance data on quality improvement at the individual provider, practice, and hospital levels.
  • Most patients will not change providers based on quality rankings, but first–time patients are more likely to choose a provider based on rankings. Many consumers do not look at performance ratings.
  • Authors suggest consumers are less interested in quality data than previously thought.
  • Evidence suggests that publicly releasing performance data stimulates hospital level quality improvement.
  • Evidence of public reporting on providers and practices is indeterminate.

Significance to Literature:

Landmark data on effect of public reporting on quality improvement.

 

(218) Rosenthal MB. Beyond Pay for Performance—Emerging Models of Provider-Payment Reform.NEJM. 2008: 359(12) 1197-1200.

PMID: 18799554

Summary:

  • Many P4P programs are changing in scope, performance measures, and magnitude of funding in order to improve efficacy.
  • New models often account for cost efficiency.
  • Models also trend towards global condition based payments such as AMI, DM2, knee replacement (Prometheus, Geisinger) developed on the basis of clinical standards for appropriate care.
  • “Need to distinguish random variation in outcomes and patient mix from variations in practices and avoidable complications.”

Significance to Literature:

Reviews several new models that combine novel reimbursement strategies with built-in quality improvement programs.

 

(286) Long JA, Helweg-Larsen M, Volpp KG. Patient Opinions Regarding ‘Pay for Performane for Patients. Journal of General Internal Medicine. 2008: 23(10) 1647-1652.

PMID: 18663540

Summary:

  • Survey of patient opinions of P4P for patients (P4P4P) programs. For example, offering positive financial incentives for smoking cessation, or charging smokers a higher premium for health insurance.
  • 53% of patients surveryed agreed or strongly agreed that people should not be paid to do things they should do anyway.
  • 36-42% thought it was a good/excellent idea, 41-44% thought it was a bad/very bad idea.

Significance to Literature:

Patient acceptance of P4P4P is not well established. More research is needed to establish benefits and burdens of P4P4P.

 

(408) Asch et al. Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial. JAMA. 2015 Nov 10;314(18):1926-35. doi: 10.1001/jama.2015.14850.

PMID: 26547464

Summary:

  • Multicenter cluster randomized clinical trial comparing the effect of physician financial incentives, patient financial incentives, shared physician and patient incentives, and no incentives on reducing levels of low-density lipoprotein cholesterol (LDL-C) in high cardiovascular risk patients
  • Patients were deemed eligible based on Framingham-Risk Scores, LDL-C levels, and presence of coronary artery disease
  • Primary care physicians and patients were randomly assigned to each group. Physicians were each eligible to receive up to $1024 annually per patient and patients could receive up to the same amount via entrance into daily lotteries based on medication adherence
  • Only patients in the shared physician/patient incentive group achieved significantly reduced LDL-C levels compared to the control group after 12-month intervention
  • Shared incentive average was 126.4 mg/dl compared to 136.4 mg/dl in the control group

Significance to Literature:

Promising evidence for physician and patient shared incentives in P4P primary schemes and an indication for further research

 

Controversial Issues

(53) Landon et al. Quality of Care in Medicaid Managed Care and Commercial Health Plans. JAMA. 2007: 298(14) 1674-1681.

PMID: 17925519

Summary:

  • Comparison of Medicaid and commercial managed care patients using 11 HEDIS quality indicators.
  • Medicaid managed enrollees receive lower quality care than commercial managed enrollees on 10 of the 11 measures.
  • These results are independent of type of insurance brand.

Significance to Literature:

Underscores the difficulty of delivering high-quality care to Medicaid patients.

 

(66) Snyder L, Neubauer RL. Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto. Annals of Internal Medicine. 2007: 127(11) 792-794.

PMID: 18056664

Summary:

  • A primary ethical concern within P4P is the unintentional adverse effect of decreasing access to unrewarded interventions.
  • Recommended action to offset adverse, avoidable effects:
    • Ensure transparency
    • Measure what is important to the patient
    • Monitor unwanted physician behavior and intervene
    • Measure continuity of care
    • Increase communication and increase access.

Significance to Literature:

P4P must take specific actions to avoid adverse effects.

 

(79) P4P is changing me. Mansfield, Richard J. Medical Economics. May 4, 2007.

Link: http://medicaleconomics.modernmedicine.com/memag/Medical+Practice+Manage...

Summary:

  • Vermont Internist recounts case example in which P4P caused tension between clinician and patient.
  • Author questions whether clinicians will comply with P4P when benefits to patients are unclear.

Significance to Literature:

Rare published personal reports.

 

(98) Rosenthal MB, Dudley RA. Pay-for-Performance: Will the Latest Payment Trend Improve Care?JAMA. Commentary. 2007: 297(7) 740-744.

PMID: 17312294

Summary:

  • The author highlights 5 Dimensions that must be considered when designing a P4P system including:
    • Who is paid
    • What is paid for
    • How much should be paid
    • How to ensure high quality
    • Should we prioritize underserved populations?
  • Provides overview of the current P4P structure and contentions.

Significance to Literature:

Overview of the controversies in design elements of P4P programs.

 

(107) Hood, RG. Pay-for-Performance—Financial Disparities and the impact on Healthcare Disparities. Journal of the National Medical Association. 2007: 99(8) 953-958.

PMID: 17722677

Summary:

  • Provides 9 inequities (reasons why P4P is unfair) for providers treating high-risk minority populations.
  • Provides 5 lessons and recommendations to overcome the above inequities and ultimately health care disparities.
  • P4P can be utilized to close the disparities gap.

Significance to Literature:

Provides many examples of how disparities should be factored into quality measurements.

 

(150) Rose J. Industry Influence in the Creation of Pay-for-Performance Quality Measures. Quality Management in Health Care. 2008: 17(1) 27-34.

PMID: 18204375

Summary:

  • Article examines which organizations influence the standards for P4P; article identifies the NCQA and the AMA-PCPI. Author says we must examine their motives, and potential for industry influence.
  • Article cites examples where drug companies have influenced clinical practice guidelines (CPGs) in the past, and how that can be problematic.
  • Author argues that experts who set the CPGs should not have ties to drug companies.
  • Mentions using Britain’s NICE program as a model for the government to establish a board that creates CPGs not influenced by industry.

Significance to Literature:

Successful P4P relies on choosing measures unbiased by industry influence.

 

(162) Campbell SM, McDonald R, Lester H. The Experience of Pay for Performance in English Family Practice: A Qualitative Study. Annals of Family Medicine. 2008: 6(3) 228-234.

PMID: 18474885

Summary:

  • Interviewed 20 nurses and 21 family doctors across England to explore beliefs and concerns about changes to service as a result of P4P between 2004-2007.
  • Many doctors and nurses acknowledged that nurses have become the primary provider of health care for patients with chronic disease, however most P4P reimbursements go to doctors.
  • The QOF achieved objectives:
    • Improved disease specific processes of patient care
    • Increased primary care physician income
    • Improved data capture
  • Lists unintended consequences including:
    • Dual QOF-patient agenda within consultations
    • Potential deskilling of doctors
    • Decline in doctor/patient continuity of care
    • Resentment by team member not benefiting financially
    • Concerns about an ongoing culture of performance monitoring

Significance to Literature:

British family doctors and nurses surveyed believe that despite benefits, P4P negatively affects relationships between doctors, nurses, and patients.

 

(174) Krumholz HM, Lee TH. Redefining Quality—Implications of Recent Clinical Trials. NEJM. Perspective. 2008: 358(24) 2537-2539.

PMID: 18539915

Summary:

  • Article written in response to ADVANCE and ACCORD trials negative intensive glucose control results in type 2 diabetes management. (170 and 173)
  • “Different strategies may have different effects on patients beyond their effect on risk-factor levels.”
  • Clinical guidelines need to reflect the strategy of intervention.
  • Provides two recommendations for performance measurement change:
    • Support the use of targets with reference to the strategies used to achieve them.
    • Guidelines should incorporate considerations of the risk of disease and adverse consequences posed by the intervention.

Significance to Literature:

Suggests appropriate responses to evidence that contradicts a specific guideline.

 

(186) Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of Patients from Pay-for-Performance Targets by English Physicians. NEJM. 2008: 359(3) 274-284.

PMID: 18635432

Summary:

  • Article first discusses the three approaches to avoiding inappropriate treatment of patients when a quality indicator does not apply when other considerations must take precedence:
    • Risk-adjust
    • Maximum achievement thresholds
    • Exception reporting
  • Analysis of data from exception reporting in the UK, including financial gain analysis, and the effect of the characteristics of patients and medical practices.
  • The median rate of exceptions in 2005-2006 was 5.3%
  • Authors conclude that exception reporting has brought substantial benefits to P4P in the UK, and there is little evidence of gaming the system.
  • Exceptions accounted for about 1.5% of the cost of the P4P program in the UK.
  • Discusses the arguments for and against exception reporting.

Significance to Literature:

Exclusion of patients is necessary in P4P, This demonstrates a successful attempt to do so.

 

(233) Werner RM, Goldman LE, Dudley RA. Comparison of Change in Quality of Care Between Safety-Net and Non-Safety-Net Hospitals. JAMA. 2008: 299(18) 2180-2187.

PMID: 18477785

Summary:

  • Authors sought to examine trends in disparities of the quality of care between hospitals with high (safety-net) and low (non-safety-net) percentages of Medicaid patients.
  • Non-safety-net hospitals improved their performance in AMI care significantly more than safety-net hospitals.
  • Safety-net hospitals are also more likely to receive smaller bonus payments and are more likely to incur penalties under P4P.
  • The CMS P4P program may exacerbate existing disparities.

Significance to Literature:

The combination of lower baseline performance and smaller gains in safety-net hospitals suggests disparities in quality of care are increasing.

 

(239) Higashi T. et al. Relationship between Number of Medical Conditions and Quality of Care. NEJM. 2008: 356(24) 2496-2504.

PMID: 17568030

Summary:

  • Authors analyzed 7,500 patients from three separate studies on disease-specific technical quality of care. 956 of which had three or more conditions.
  • “Linear regression analysis showed that each additional condition was associated with a 2.2% increase in the quality score,” in one study, and a 1.7% increase in each of the other two studies.
  • The relationship between increased and the number of conditions was less significant if the patient had more than seven conditions, or did not see a specialist.

Significance to Literature:

“This finding does not provide support for the argument that incentive programs based on quality indicators of care processes will necessarily penalize providers who provide care to patients with multiple conditions."

 

(241) Shen Y. Selection Incentives in a Performance-Based Contracting System. Health Services Research. 2003: 38(2) 535-552.

PMID: 12785560

Summary:

  • Author investigated whether a P4P program provided incentives for a nonprofit substance abuse treatment center to treat less severe clients.
  • P4P was implemented in the study group (OSA) but not in the control group (Medicaid).
  • Prior to the implementation of P4P the study group had 11% more severe cases than the control group, whereas after three years of P4P, the study group had 28.5% fewer severe cases than the control group.
  • Study identifies “the selection effect” as just one unintended consequence of P4P.

Significance to Literature:

First study to show major selection bias likely resulting from the implementation of a P4P program.

 

(360) Dorsey ER, Ritzer G. The McDonaldization of Medicine. JAMA Neurology. 2016 Jan 1; 73(1): 15-6. doi: 10.1001/jamaneurol.2015.3449.

PMID: 26569617

Summary:

  • “Viewpont” article, criticizes elements of modern medical practice which parallel the four basic principles of McDonaldization - efficiency, calculability, predictability, and control:
    • Efficiency: Less expensive and skilled clinicians often hired to reduce visit time with patients
    • Calculability: The care patients receive is increasingly based on the overall cost to the system
    • Predictability: Scripted histories, excessive checklists, and uniform patient visit lengths
    • Control - Patient-physician dialogue is determined increasingly by what the electronic medical record requires
  • McDonaldization can dehumanize the doctor-patient relationship and “replaces energy and empathy with fatigue and inertia in residents and burnout in physicians”

Significance to Literature:

Authors’ “Viewpoint” article cautions “McDonaldization results in unreasonable systems that deny the humanity, the human reason, of the people who work within them or are served by them.”

 

(369) Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf. 2015 Dec 30. pii: bmjqs-2015-005003. doi: 10.1136/bmjqs-2015-005003. [Epub ahead of print]

PMID: 26717988

Summary:

  • United Kingdom’s pay-for-performance program, Quality and Outcomes Framework, allows for general practitioners to exclude patients from quality calculations without financial penalty
  • This practice, known as exception reporting, was designed to allow providers to use clinical judgement to exempt patients from evidence-based guidelines when not applicable and protect physicians from patient non-compliance, but has been controversial.
  • Notable points include:
    • 1% of practices were responsible for 15% of all exception reporting
    • Higher target quality markers are associated with higher rates of exception reporting
    • Increased exception reporting for complex patients with multiple comorbidities
    • Patients from lower socioeconomic areas are more likely to be exception reported
    • Exception reporting is associated with increased risk of death for patients

Significance to Literature:

Physicians exception reported uncommonly yet more work needs to be done to better understand if and when providers’ decisions to circumvent evidence-based guidelines is appropriate.

 

(420) Lin et al. Impact of pay for performance on behavior of primary care physicians and patient outcomes. J Evid Based Med. 2015 Dec 12. doi: 10.1111/jebm.12185. [Epub ahead of print].

PMID: 26667492

Summary:

  • Systematic review of 44 studies to assess the impact of P4P on primary care physician behavior and patient outcomes
  • Overall positive effect was found for the management of disease although process outcomes often improved more than endpoint outcomes
  • Baseline quality of medical care and the size of practice both limit performance improvement
  • Unintended consequences associated with P4P were found to include:
    • Rising medical costs for programs without financial metrics
    • Inconsistent effects on health equity - some programs improved and some programs exacerbated inequities related to sex, age, ethnicity, socioeconomic status, comorbidity/severity, duration of illness, and size of practice.
    • Inconsistency in patient satisfaction (some increased and some decreased patient satisfaction)

Significance to Literature:

Evidence for P4P has shown positive clinical effects for most diseases, but implementation may bring about negative unintended consequences, particularly related to health equity.

 

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