Provider Viewpoint

 

One way to measure negative effects and unintended consequences of P4P programs is to formally interview health care providers. This provides data regarding physician intent, physician consideration, and workplace environment. If physicians report any scheming, or firing patients to meet bonuses, programs may have to be halted. To date however, most physician's interviewed have stated a generally positive attitude towards P4P (73, 165, 249, 300).  However, it is worth noting that McDonald (165) reports a difference in perception between nurse and physician opinion because nurses have an increased workload, but do not share a part of the quality bonus. Additionally, Culhane-Pera et al. (462) noted the possibility that P4P can incentivize "checking boxes" over providing quality care, as well as its potential to exacerbate health care disparities.

 

 

Provider Viewpoint Literature

(73) Physicians have positive attitudes about pay-for-quality programs, but are ambivalent about certain program features. AHRQ September, 2007. No. 325.

Link: http://www.ahrq.gov/RESEARCH/sep07/0907RA26.htm

Summary:

  • Recent survey of primary care physicians in California and Massachusetts:
  • Many physicians think positively of P4P, but report negatively about their understanding of the details of programs.
  • Many doctors think P4P can improve quality care.

Significance to Literature:

In September 2007 physicians in Massachusetts and California were “neither disaffected from nor fully engaged in P4Q (Pay-for-Quality) programs.”

 

 

(165) McDonald R, Harrison S, Checkland K. Incentives and control in primary health care: findings from English pay-for-performance case studies. Journal of Health Organization and Management. 2008: 22(1) 48-62.

PMID: 18488519

Summary:

  • In-depth qualitative case study of two GP clinics in England seeking to find perceptions of control after P4P implementation.
  • Overall attitudes towards P4P were positive. However nurses expressed more discontent with increase surveillance, insufficient wage increases for workload, and negative consequences for patient-centered care.
  • Discontent was observed with more intensive surveillance.

Significance to Literature:

Highlights differences between physician and nurse experiences with England’s Quality and Outcome Framework (QOF) P4P program and concludes that intense surveillance may have the potential to constrain clinical practice.

 

 

(249) Leas BF, Goldfarb NI, Browne RC, Kerorack M, Nash DB. Ambulatory Quality Improvement in Academic Medical Centers: A Changing Landscape. American Journal of Medical Quality. 2009: 24(4) 287-94.

PMID: 19411626

Summary:

  • Compares a survey of Academic Centers ambulatory quality improvement infrastructure published in 2004 with a current survey conducted in 2006.
  • Institutional support for quality initiatives and sustained improvement substanially increased between the two surverys.
  • More than half of surveryed Academic Medical Centers (AMCs) reported already participating in commercial quality improvement initiatives, and two thirds expected further expansion in quality improvement programs.
  • In contrast, less than half of AMCs planned to participate in public reporting programs.

Significance to Literature:

AMCs report an expanded capacity to participate in P4P programs as part of quality improvement programs.

 

 

(300) Damberg CL, Raube K, Teleki SS, Cruz ED. Taking Stock of Pay-For-Performance: A Candid Assessment From The Front Lines. Health Affairs. 2009: 28(2) 517-525.

PMID: 19276011

Summary:

  • Authors interviewed a non-randomized sample of 35 physician organizations participating in California’s Integrated Healthcare Association’s statewide P4P program.
  • Authors presented many results based on physicians experience with P4P in their clinic:
    • 25/31 believe that P4P has increased accountability for quality, improved data collection, and created greater organizational focus for QI projects.
    • Some groups were quoted as saying P4P “isn’t worth the trouble.”
    • 9 gave examples of negative consequences, however >66% reported more positives than negatives created.
    • 23 reported believe P4P was either very important or important.
    • There was widespread support for increasing incentives
    • Health plans stated P4P program had not met original goals yet.

Significance to Literature:

Provides insight and advice from physician organizations in one of the biggest P4P programs in the country.

 

 

(343) Shuaib W. Award Incentives to Improve Quality Care in Internal Medicine. Irish Journal of Medical Science. 2015 Jun;184(2):483-6. doi: 10.1007/s11845-014-1150-z. Epub 2014 Jun 4.

PMID: 24893851

Summary:

  • Development and implementation of internal medicine awards program
  • Pre-award survey was sent out electronically to faculty of internal medicine department to understand desire for employee recognition through an awards program
  • Five awards created included compassionate physician award, best service award, best mentor award, decade of excellence in teach award, and a scientific award for research
  • In a post-award survey, 78% of respondents stated award incentives would result in increased quality of personal performance

Significance to Literature:

Award incentives as chosen by peers may elevate personal performance and advance patient care quality.

 

 

Key Article

(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.

 

 

(379) Hackett et al. ‘Just another incentive scheme’: a qualitative interview study of local pay-for-performance scheme for primary care. BMC Fam Pract. 2014 Oct 25;15:168. doi: 10.1186/s12875-014-0168-7.

PMID: 25344735

Summary:

  • Retrospective semi-structured interviews of 46 professionals were conducted to assess whether their experiences differed with development/implementation of local P4P schemes versus United Kingdom national programs such as the Quality and Outcomes Framework
  • Results indicated negligible ownership difference between local and national schemes but a variation in physician motivators between practices serving higher and lower socioeconomic groups

Significance to Literature:

No evidence for differences in experiences with local P4P adaptations versus a national scheme

 

 

(409) Waddimba et al. The Moderating Effect of Job Satisfaction on Physicians’ Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines. Med Care Res Rev. 2016 Feb 9. pii: 1077558716628354. [Epub ahead of print]

PMID: 26860890

Summary:

  • Retrospective cohort study examining the indirect, moderating effect of professional satisfaction on adherence to P4P diabetes guidelines within New York’s Value of Care Plan (VOCP)
  • From 2002-2003 “Quality Targets and Incentives” survey was responded to by 290 eligible PCP’s
  • Survey collected data on the attitudes of PCP’s regarding both P4P in general and VOCP
  • Results showed that physicians who were dissatisfied with their practice were only motivated to adhere to diabetes guidelines which favored their personal inclinations and were also less likely to adhere when social pressures urged them to comply to guidelines
  • Strong awareness of measures and belief in their efficacy, as well as satisfaction with the value of financial incentives, increased adherence among discontented physicians
  • “Neither attitudinal nor social pressures significantly influenced satisfied physicians” (They adhered more to the guidelines.)

Significance to Literature:

More satisfied providers adhere more to P4P incentivized diabetes guidelines

 

(444) Liu et al. Physician attitudes toward participating in a financial incentive program for LDL reduction are associated with patient outcomes. Healthc (Amst). 2016 Dec 5. pii: S2213-0764(16)30001-X. doi: 10.1016/j.hjdsi.2016.09.002. [Epub ahead of print]

PMID: 27932264

Summary:

  • The results of a previous study (408) indicated that providing incentives to both physicians and patients had the greatest impact on statin medication adherence and low-density lipoprotein cholesterol (LDL-C) reduction compared to physician/patient incentives alone or no incentives
  • This present study was performed by quantitative survey analyses and post-study interviews of physicians from each arm of the previous study to evaluate if:
    • Primary care physicians (PCPs) perceive financial incentive programs differently before and after participating
    • PCP attitudes about financial incentives vary by physician or practice characteristics
    • PCP attitudes about financial incentives are associated with clinical outcomes
  • Results from the surveys and interviews indicated:
    • Physicians generally approve of offering financial incentives to physicians and patients and this belief did not change substantially after study participation
    • No change in beliefs about offering financial incentives to physicians or patients was found based on physician age, experience, or number of enrolled patients
      • When asked how to distribute a hypothetical $1000 in incentives, 66% suggested they should be shared, with only 7% suggesting those dollars go to the physician alone
    • Patients in shared incentive groups had a greater reduction in LDL-C than patients in control groups provided their physician agreed with offering incentives (irrespective of whether the physician supported physicians/patient incentives alone or to share the incentive)
    • Most physicians stated they never discussed either the patients’ or their own financial incentives with the patients, but over half indicated helping patients achieve financial incentives was important to them
      • The majority of respondents said the study had no effect on their relationship with patients with some even reporting positive effects

Significance to Literature:

A unique look at physician attitudes towards incentives for patients and physicians as well as the impact of this perspective on patient outcomes in a shared financial incentive intervention.

 

(445) Lochner et al. Family Physician Clinical Compensation in an Academic Environment: Moving Away From the Relative Value Unit. Fam Med. 2016 Jun;48(6):459-66.

PMID: 27272423

Summary:

  • Observational study of provider viewpoint and relative value unit (RVU) productivity within the University of Wisconsin-Madison Department of Family Medicine and Community Health (DFMCH) before and after implementation of a new physician compensation plan for both residency teaching clinic faculty and community clinic faculty
    • New compensation plans decreased emphasis on RVU productivity and increased patient panel management-based compensation
    • Community faculty had 50% of salary based on RVU productivity whereas resident faculty had only 20%
  • Results included:
    • Greatly increased satisfaction (up to 60% improvement for community faculty) for both residency and community faculty with regards to compensation structure and amount
    • No DFMCH physicians left to work for local competitors (a recent problem prior to compensation reform)
    • For both groups, panel size per clinical full-time equivalent increased
    • RVU productivity increased 22.6% in community clinics and decreased the same amount in residency clinics, but both moved closer to national family medicine RVU benchmarks

Significance to Literature:

Moving compensation emphasis away from RVU productivity can improve physician satisfaction and retention as well as increase panel sizes, but changes in RVU can be difficult to predict.

 

(462) Culhane-Pera et al. Primary care clinicians’ perspectives about quality measurements in safety-net clinics and non-safety-net clinics. International Journal for Equity in Health. 2018

PMID:  30404635

Summary:

  • Qualitative interviews and focus groups with 14 PCPs with experience in both safety-net and non-safety-net primary care clinics in the Minneapolis-St. Paul metropolitan areas
  • Analyses of interview/focus group transcripts led to the emergence of three major themes:
    • Minnesota’s currently quality scores are influenced more by patients and clinic systems than by individual clinicians
    • Collecting data in order to “check boxes” and fulfill a set of specific quality measures is not the same as measuring true quality in healthcare (Subtheme – current quality measures do not align with how patients and clinicians define quality healthcare)
    • Current quality measures are both the products of and are embedded within social and structural inequities within the American healthcare system (Subthemes – the current inequities within the healthcare system should not be reinforced by financial payments; thus, true health equity requires the development of new metrics and a new healthcare system)

Significance to Literature:

Perspectives from PCPs with experience in both safety-net and non-safety-net clinical settings provides increased insight into the ways aligning payment with current quality metrics can perpetuate or exacerbate existing social inequities and health disparities.