Laura A. Petersen, MD, MPH; LeChauncy D. Woodard, MD, MPH; Tracy Urech, BA; Christina Daw, MPH; Supicha Sookanan, MPH
Disclaimer: The views expressed in this article are solely the authors' and do not necessarily represent those of the Veterans Administration.
Grant Support: In part by VA HSR&D IIR 04-349 (Dr. Petersen, Principal Investigator) and NIH RO1 HL079173-01 (Dr. Petersen, Principal Investigator). Dr. Petersen is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (grant no. 045444) and a recipient of the American Heart Association Established Investigator Award (grant no. 0540043N).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Laura A. Petersen, MD, MPH, Health Services Research and Development (152), Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030; e-mail, email@example.com.
Current Author Addresses: Drs. Petersen and Woodard, Ms. Daw, and Ms. Sookanan: Health Services Research and Development (152), Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030.
Ms. Urech: VA Boston Health Care System—Jamaica Plain Campus, 150 South Huntington Avenue, Jamaica Plain, MA 02130.
Most physicians and hospitals are paid the same regardless of the quality of the health care they provide. This produces no financial incentives and, in some cases, produces disincentives for quality. Increasing numbers of programs link payment to performance.
To systematically review studies assessing the effect of explicit financial incentives for improved performance on measures of health care quality.
PubMed search of English-language literature (1 January 1980 to 14 November 2005), and reference lists of retrieved articles.
Empirical studies of the relationship between explicit financial incentives designed to improve health care quality and a quantitative measure of health care quality.
The authors categorized studies according to the level of the incentive (individual physician, provider group, or health care payment system) and the type of quality measure rewarded.
Thirteen of 17 studies examined process-of-care quality measures, most of which were for preventive services. Five of the 6 studies of physician-level financial incentives and 7 of the 9 studies of provider group-level financial incentives found partial or positive effects on measures of quality. One of the 2 studies of incentives at the payment-system level found a positive effect on access to care, and 1 showed evidence of a negative effect on access to care for the sickest patients. In all, 4 studies suggested unintended effects of incentives. The authors found no studies examining the optimal duration of financial incentives for quality or the persistence of their effects after termination. Only 1 study addressed cost-effectiveness.
Few empirical studies of explicit financial incentives for quality were available for review.
Ongoing monitoring of incentive programs is critical to determine the effectiveness of financial incentives and their possible unintended effects on quality of care. Further research is needed to guide implementation of financial incentives and to assess their cost-effectiveness.
Studies published between 1 January 1980 and 14 November 2005 and evaluated for inclusion in the systematic review of explicit financial incentives for health care quality.
Table 1. Excluded Articles and Reason for Exclusion
Table 2. Proposed Research Agenda for Studying Explicit Financial Incentives in Health Care
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Mark A Van Swol
September 14, 2006
Will Primary Care Survive P4P
To the Editor:
RE: Will Primary Care Survive P4P?
I read with great interest the article "Does Pay-for-Performance Improve the Quality of Healthcare" in the August 15, 2006, edition of Annals of Internal Medicine. Dr Peterson and colleagues provide an excellent introduction to pay-for-performance initiatives with a special emphasis on determining the proof for its effectiveness in the literature.
I agree with the authors that more research needs to be done in the area of pay-for-performance and particularly in examining unintended negative outcomes of such a system. The authors then propose an agenda for future research.
Two additional areas must be considered for future research. First, documenting and reporting this data is the biggest hurdle in pay-for- performance programs and can only be done through some type of electronic health record. This is the greatest financial disincentive to physicians.1 This great burden is placed largely on a group of physicians who already are the least compensated yet have the highest demands"”the primary care physician.2
Since our system still is based on quantity of care rather than quality of care, it is financially more rewarding to see one more patient a day then it is to provide high quality of care to the other patients.2 Rural or solo practitioners will have the high upfront cost in implementing an electronic health record and therefore will be discouraged from trying to report and improve care.3 Even if electronic health records are shown to improve care, their widespread use will not happen until our system of healthcare is changed. 4 In our region, few private physician offices have implemented electronic health records.
It is apparent that there will be both a shortage of primary-care physicians and more pay-for"“performance programs based on quality indicators. If greater demands are placed on primary-care physicians without support, there may be less physicians who can afford to provide this high quality of care. Any future discussion concerning pay-for- performance should include providing support to primary care physicians to implement an electronic health record for every patient.
1 Inform Prim Care. 2004;12(1):3-9Barriers to proliferation of electronic medical records.
2 Bodenheimer, T. NEJM 355;9: 861-869. Primary Care "” Will It Survive? .
3 Health Aff (Millwood). 2005 Sep-Oct;24(5):1127-37. The value of electronic health records in solo or small group practices
4 Health Affairs, 24, no. 5 (2005): 1103-1117 Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs
Steven M. Hegedus
September 26, 2006
Does Pay-for-Performance Improve the Quality of Health Care?
Dr. Petersen and colleagues review the emerging concept of physician pay-for-performance, and in their analysis, several important questions arise. One understated but critical variable remains the effect on underserved patient populations.
In their discussion of the unintended effects of financial incentives, the authors site the possibility that the most severely ill patients may be avoided as health care providers attempt to "game" the system. Beyond this immediate patient selection, populations of under- ensured patients face well-documented challenges (2,3), and thus outcomes- based measurements may serve to further isolate this marginalized group. For instance, Rates of smoking cessation, levels of blood pressure control, and percentage of glycated hemoglobin, differ with socioeconomic class (4,5). Regularly, in the urban city clinic in which I practice, I see patients struggling with addiction, poverty, and violence, and measuring outcomes of these patients beside others, I fear, may serve to further devalue the care they receive, and dissuade physicians from choosing to care for the underserved. Likewise, if financial incentives remain tied to outcomes-based variables, mission-based medical centers will be most impacted, losing funding, insured patients, and health care providers, all in the name of improving care.
Dr. Peterson and colleagues describe that "Incentives require very careful design," and this is unquestionably true. It seems that an era of pay-for-performance is approaching, though the overall impact on quality of care, patient/provider satisfaction, and health care costs remain uncertain. This is a time for careful consideration and evidence-based decision making, and also a time to consider the impact of our decisions on every segment of population, particularly those with the greatest need.
References 1. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for- performance improve the quality of health care? Ann Intern Med. 2006;145:265-72.
2. American College of Physicians. Racial and ethnic disparities in health care, a position paper of the American College of Physicians. Ann Intern Med. 2004;141:226-32.
3. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in medicare managed care. N Eng J Med. 2005;353(19):692-700.
4. Saaddine JB et al. Improvements in diabetic processes of care and intermediate outcomes: United States, 1988-2002. Ann Intern Med. 2006;144(7):465-74.
5. Siahpush M, Heller G, Singh G. Lower levels of occupation, income, and education are strongly associated with a longer smoking duration: multivariate results from the 2001 Australian national drug strategy survey. Public Health. 2005;119(12):1105-10.
Laura A. Petersen
Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, 77030
October 26, 2006
Pay for Performance -- Author response
Dr. Van Swol appropriately highlights the importance of the valid, reliable assessment of the quality of health care as the foundation of pay -for-performance programs. He asserts that this can only be achieved via a universal electronic health record, and points out the disproportionate burden of implementing electronic health records in the solo and rural primary health care delivery setting. While agreeing with Dr. Van Swol on many points, it is important to note that there is very poor uptake of this technology overall (1), and that there is a great degree of variability in the types and interoperability of electronic health records that are being implemented (2). This ensures that data variability and consistency across different sites are now and will continue to be very problematic, and could threaten performance monitoring and pay-for- performance programs in the very health care delivery settings where these programs could have the greatest positive impact. While there is legislation under development to provide financial incentives to implement electronic health records (3), it is apparent that methods for valid quality measurement that are independent of electronic health records are urgently needed. The basic science of quality measurement needs to advance to keep pace with policy reforms, and we need to create broad, clinically meaningful measures of health care quality. For example, we need to assess whether claims-based data supplemented with limited clinical data collection or patient surveys could provide acceptable data for performance monitoring purposes at the group or hospital level in the near term. The National Institutes of Health and the Agency for Healthcare Research and Quality have great potential for influence in this area. With advances in the science of quality measurement, the hope is that nascent quality based purchasing reforms do not stall or, worse, undergo a backlash similar to that suffered by managed care reforms in the last decade.
(1) Jha AK, Ferris TG, Donelan K et al. How Common Are Electronic Health Records In The United States? A Summary Of The Evidence. Health Aff (Millwood). 2006 Oct 11; [Epub ahead of print] PMID: 17035341 (2) Valdes IH, Kibbe D, Tolleson G, Kunik ME, Petersen LA. Barriers to proliferation of electronic medical records. Inform Prim Care. 2004;12(1):3-9. (3) U.S. House. 109th Congress, 2nd Session. H.R. 4157. Health Information Technology Promotion Act of 2006. ONLINE. Library of Congress (THOMAS). Available: http://thomas.loc.gov [26 Oct 2006].
Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does Pay-for-Performance Improve the Quality of Health Care?. Ann Intern Med. 2006;145:265-272. doi: 10.7326/0003-4819-145-4-200608150-00006
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Published: Ann Intern Med. 2006;145(4):265-272.
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