OBJECTIVES: To test the impact of provider performance pay for anaemia reduction in rural China.
DESIGN: A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment.
SETTING: 72 randomly selected rural primary schools across northwest China.
PARTICIPANTS: 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study.
INTERVENTIONS: Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point).
MAIN OUTCOME MEASURES: Student haemoglobin concentrations.
RESULTS: Mean student haemoglobin concentration rose by 1.5 g/L (95% CI -1.1 to 4.1) in information schools, 0.8 g/L (-1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools.
CONCLUSIONS: Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.
TRIAL REGISTRATION NUMBER: ISRCTN76158086.
OBJECTIVES: The Cesarean section (CS) rate in Taiwan has exceeded 30% since 2000. To lower the CS rate, the Bureau of National Health Insurance in Taiwan raised the payment for vaginal delivery (VD) in May 2005, and also increased the insured's copayment for elective CS in May 2006. This study clarifies the influences of these financial incentives, and explores whether the 2 policies lowered the CS rate.
STUDY DESIGN: The materials used are birth cases obtained from a systematic sampling of the original inpatient claim data in the National Health Insurance research database between 2003 and 2007. The empirical analysis of this study groups the birth data into 4 types: VD, unplanned CS, planned CS, and elective CS.
METHODS: The 4 delivery types represent the dependent variable. A multinomial logistic regression model was adopted as the empirical method. The policy changes, hospital attributes, and insured status were considered independent variables.
RESULTS: Results indicate that the supply-side policy change in May 2005 reduced the number of CS cases. However, the policy effect was not very significant, and the CS rate decreased mainly because of planned CS cases. The demand-side policy change in May 2006 did not lower the rate of elective CS.
CONCLUSIONS: The results imply that the financial incentives were not the main consideration for both the demand and supply sides. To encourage more VDs and lower the CS rate, the authorities could consider mechanisms other than adjusting the payment or changing the copayment.
PURPOSE: We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes.
METHODS: We undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A(1c) (HbA(1c)), total cholesterol, and blood pressure.
RESULTS: The introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: -1.68 mm Hg; 95% CI, -2.41 to -0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (-1.01 mm Hg; 95% CI, -1.79 to -0.24 mm Hg) and in cholesterol in white (-0.13 mmol/L; 95% CI, -0.21 to -0.05 mmol/L) and black (-0.10 mmol/L; 95% CI, -0.20 to -0.01 mmol/L) patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA(1c) in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA(1c): white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period.
CONCLUSION: A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.
BACKGROUND: The Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?
METHODOLOGY/PRINCIPAL FINDINGS: Retrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.
CONCLUSIONS/SIGNIFICANCE: Pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed.
BACKGROUND: Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda.
METHODS: 166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics.
FINDINGS: Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026-0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines.
INTERPRETATION: The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health.
FUNDING: World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network.
Financial incentives in primary care have been introduced with the purpose of improving appropriateness of care and containing demand. We usually observe pay-for-performance programs, but alternatives, such as pay-for-participation in improvement activities and pay-for-compliance with clinical guidelines, have also been implemented. Here, we assess the influence of different programs that ensure extra payments to GPs for containing avoidable hospitalisations. Our dataset covers patients and GPs of the Italian region Emilia-Romagna for the year 2005. By separating pay-for-performance from pay-for-participation and pay-for-compliance programs, we estimate the impact of different financial incentives on the probability of avoidable hospitalisations. As dependent variable, we consider two different sets of conditions for which timely and effective primary care should be able to limit the need for hospital admission. The first is based on 27 medical diagnostic related groups that Emilia-Romagna identifies as at risk of inappropriateness in primary care, while the second refers to the internationally recognised ambulatory care-sensitive conditions. We show that pay-for-performance schemes may have a significant effect over aggregate indicators of appropriateness, while the effectiveness of pay-for-participation schemes is adequately captured only by taking into account subpopulations affected by specific diseases. Moreover, the same scheme produces different effects on the two sets of indicators used, with performance improvements limited to the target explicitly addressed by the Italian policy maker. This evidence is consistent with the idea that a "tunnel vision" effect may occur when public authorities monitor specific sets of objectives as proxies for more general improvements in the quality of health care delivered.
OBJECTIVE: To test the effect of Massachusetts Medicaid's (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP).
DATA: Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N=62) and other states (N=3,676) and American Hospital Association data on hospital characteristics from 2005.
STUDY DESIGN: Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics.
PRINCIPAL FINDINGS: Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (-0.67 percentage points, p>.10) and SIP (-0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications.
CONCLUSIONS: Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.
PURPOSE: The efficacy of rewarding physicians financially for preventive services is unproven. The objective of this study was to evaluate the effect of a physician pay-for-performance program similar to the Medicare Physician Quality Reporting Initiative program on quality of preventive care in a network of community health centers.
METHODS: A retrospective review of administrative data was done to evaluate a natural quasi-experiment in a network of publicly funded primary care clinics. Physicians in 6 of 11 clinics were given a financial incentive twice the size of the current Centers for Medicare and Medicaid Services' incentive for achieving group targets in preventive care that included cervical cancer screening, mammography, and pediatric immunization. They also received productivity incentives. Six years of performance indicators were compared between incentivized and nonincentivized clinics. We also surveyed the incentivized clinicians about their perception of the incentive program.
RESULTS: Although some performance indicators improved for all measures and all clinics, there were no clinically significant differences between clinics that had incentives and those that did not. A linear trend test approached conventional significance levels for Papanicolaou smears (P = .08) but was of very modest magnitude compared with observed nonlinear variations; there was no suggestion of a linear trend for mammography or pediatric immunizations. The survey revealed that most physicians felt the incentives were not very effective in improving quality of care.
CONCLUSION: We found no evidence for a clinically significant effect of financial incentives on performance of preventive care in these community health centers. Based on our findings and others, we believe there is great need for more research with strong research designs to determine the effects, both positive and negative, of financial incentives on clinical quality indicators in primary care.
OBJECTIVE: To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.
DESIGN: Longitudinal analysis.
SETTING: 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.
PARTICIPANTS: 2 523 659 adult members of Kaiser Permanente Northern California. Main outcomes measures Yearly assessment of patient level glycaemic control (HbA(1c) <8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure <140 mm Hg), and screening for cervical cancer.
RESULTS: Incentives for two indicators-screening for diabetic retinopathy and for cervical cancer-were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening.
CONCLUSION: Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.
We examined the impact of a major pay-for-performance initiative introduced into UK primary care in 2004 on disparities in diabetes management between age, sex, and socioeconomic groups in this retrospective cohort study. We used data from the General Practice Research Database enrolling 422 family practices. Existing disparities in risk factor management (HbA1c, blood pressure, cholesterol) narrowed between men and women. Younger patients (<45 years) with diabetes appear to have benefited less from Quality and Outcomes Framework than older patients, resulting in some widening of existing age group disparities. Patients living in affluent and deprived areas appeared to have derived a similar level of benefit from pay for performance.
To test the impact of provider performance pay for anaemia reduction in rural China.
DESIGN:
A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment.
SETTING:
72 randomly selected rural primary schools across northwest China.
PARTICIPANTS:
3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study.
INTERVENTIONS:
Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point).
MAIN OUTCOME MEASURES:
Student haemoglobin concentrations.
RESULTS:
Mean student haemoglobin concentration rose by 1.5 g/L (95% CI -1.1 to 4.1) in information schools, 0.8 g/L (-1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools.
CONCLUSIONS:
Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.
