BACKGROUND: Pay-for-performance (P4P) intents to stimulate both more effective and more efficient health care delivery. To date, evidence on whether P4P itself is an efficient method has not been systematically analyzed.
OBJECTIVE: To identify and analyze the existing literature regarding economic evaluation of P4P.
DATA SOURCES: English, German, Spanish, and Turkish language literature were searched in the following databases: Business Source Complete, the Cochrane Library, Econlit, ISI web of knowledge, Medline (via PubMed), and PsycInfo (January 2000-April 2010).
STUDY SELECTION: Articles published in peer-reviewed journals and describing economic evaluations of P4P initiatives. Full economic evaluations, considering costs and consequences of the P4P intervention simultaneously, were the prime focus. Additionally, comparative partial evaluations were included if costs were described and the study allows for an assessment of consequences. Both experimental and observational studies were considered.
RESULTS: In total, nine studies could be identified. Three studies could be regarded as full economic evaluations, and six studies were classified as partial economic evaluations. Based on the full economic evaluations, P4P efficiency could not be demonstrated. Partial economic evaluations showed mixed results, but several flaws limit their significance. Ranges of costs and consequences were typically narrow, and programs differed considerably in design. Methodological quality assessment showed scores between 32% and 65%.
CONCLUSION: The results show that evidence on the efficiency of P4P is scarce and inconclusive. P4P efficiency could not be demonstrated. The small number and variability of included studies limit the strength of our conclusions. More research addressing P4P efficiency is needed.
BACKGROUND: The use of blended payment schemes in primary care, including the use of financial incentives to directly reward ‘performance’ and ‘quality’ is increasing in a number of countries. There are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system-wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care.
OBJECTIVES: The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:
i) the different types of financial incentives that have improved quality;
ii) the characteristics of patient populations for whom quality of care has been improved by financial incentives; and
iii) the characteristics of PCPs who have responded to financial incentives.
SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet-based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009.
SELECTION CRITERIA: Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals.
MAIN RESULTS: Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups’ performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Three cluster RCTs examined smoking cessation; one CBA examined patients' assessment of the quality of care; one CBA examined cervical screening, mammography screening, and HbA1c; one ITS focused on four outcomes in diabetes; and one controlled ITS (a difference-in-difference design) examined cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia screening, and appropriate asthma medication. Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care. Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan.
AUTHORS' CONCLUSIONS: The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.
BACKGROUND: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.
METHODS: The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.
RESULTS: One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.
CONCLUSIONS: P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.
OBJECTIVES: To assess the impact of pay for performance programmes on inequalities in the quality of health care in relation to age, sex, ethnicity and socioeconomic status.
METHODS: Systematic search and appraisal of experimental or observational studies that assessed quantitatively the impact of a monetary incentive on health care inequalities. We searched published articles in English identified in the MEDLINE, EMBASE, PsycINFO and Cochrane databases.
RESULTS: Twenty-two studies were identified, 20 of which were conducted in the United Kingdom and examined the impact of the Quality and Outcomes Framework. Sixteen studies used practice level data rather than patient level data. Socioeconomic status was the most frequently examined inequality; age, sex and ethnic inequalities were less frequently assessed. There was some weak evidence that the use of financial incentives reduced inequalities in chronic disease management between socioeconomic groups. Inequalities in chronic disease management between age, sex and ethnic groups persisted after the use of such incentives.
CONCLUSION: Inequalities in chronic disease management have largely persisted after the introduction of the Quality and Outcome Framework. Pay for performance programmes should be designed to reduce inequalities as well as improve the overall quality of care.
BACKGROUND: A new contract between UK primary care practices and government was implemented in April 2004, with substantial financial rewards to general practices for achievement of standards set out in the Quality and Outcomes Framework (QOF).
AIM: We aimed to review the evidence about the effects of the QOF on health care, including unintended outcomes, and equity.
METHODS: Relevant papers were identified by searching Medline and from the reference lists of published reviews and papers. A separate systematic literature review was conducted to identify papers with information on the impact of the framework on inequalities.
RESULTS: All studies were observational, and so it cannot be assumed that any changes were caused by the framework. The results both for individual indicators and from different studies vary substantially. The diverse nature of the research precluded formal synthesis of data from different studies. Achievement of quality standards was high when the contract was introduced, and has risen each year roughly in line with the pre-existing trend. Inequalities in achievement of standards were generally small when the framework was implemented, and most have reduced further since. There is weak evidence that achievement for conditions outside the framework was lower initially, and has neither worsened nor improved since. Some interventions in the framework may be cost-effective. Professionals feel consultations and continuity have suffered to some extent. There is very little research about patients' views, or about the aspects of general practice not measured, such as caring, context and complexity.
CONCLUSION: The evidence base about the impact of the QOF is growing, but remains patchy and inconclusive. More high quality research is needed to inform decisions about how the framework should change to maximise improvements in health and equity.
Information on the impact of pay-for-performance programs is lacking in the nursing home setting. This literature review (1980-2007) identified 13 prior examples of pay-for-performance programs in the nursing home setting: 7 programs were active as of 2007, while 6 had been terminated. The programs were mostly short-lived, varied considerably in the choice of performance measures and pay incentives, and evaluations of the impact were rare.
Performance-based payment (PBP) is increasingly advocated as a way to improve the performance of health systems in low-income countries. This study conducted a systematic review of the current literature on this topic and found that while it is a popular term, there was little consensus about the meaning or the use of the concept of PBP. Significant weaknesses in the current evidence base on the success of PBP initiatives were also found. The literature would be strengthened by multi-disciplinary case studies that present both the advantages and disadvantages of PBP, influential factors for success, and more details about the projects from which this evidence is drawn. Where possible, data from control facilities where PBP is not being implemented would be an important addition. This paper suggests a further agenda for research, including assessing optimal conditions for implementation of PBP schemes in less developed health systems, the impact of adopting measures of performance as targets, and the requirements for monitoring PBP adequately.
More than 40 private sector hospital pay-for-performance (P4P) programs now exist, and Congress is considering initiating a Medicare hospital P4P program. Given the growing interest in hospital P4P, this systematic review of the literature examines the current state of knowledge about the effect of P4P on clinical process measures, patient outcomes and experience, safety, and resource utilization. Little formal evaluation of hospital P4P has occurred, and most of the 8 published studies have methodological flaws. The most rigorous studies focus on clinical process measures and demonstrate that hospitals participating in the Centers for Medicare and Medicaid Services-Premier Hospital Quality Incentive Demonstration, a P4P program, had a 2- to 4-percentage point greater improvement than the improvement observed in control hospitals. There is a need for more systematic evaluation of hospital P4P to understand its effect and whether the benefits of investing in P4P outweigh the associated costs.
There has been a growing interest in the use of financial incentives to encourage improvements in the quality of health care. Several articles have reviewed past studies of the impact of specific incentive arrangements, but these studies addressed small-scale experiments, making their findings arguably of limited relevance to current improvement efforts. In this article, the authors review evaluations of more recent pay-for-performance initiatives instituted by health plans or by provider organizations in cooperation with health plans. Findings show improvement in selected quality measures in most of these initiatives, but the contribution of financial incentives to that improvement is not clear; the incentives typically were implemented in conjunction with other quality improvement efforts, or there was not a convincing comparison group. However, the literature relating to purchaser pay-for-performance initiatives does underscore several important issues that deserve attention going forward that relate to the design and implementation of pay-for-performance initiatives.
PURPOSE OF REVIEW: To summarize studies of pay-for-performance programmes designed to address clinical quality of care markers in ambulatory settings at the level of the physician group or individual physician.
RECENT FINDINGS: Seven randomized controlled trials and 15 nonrandomized studies were reviewed. Less than half of the randomized controlled trials showed positive results, whereas all but one of the nonrandomized studies showed positive or mixed results. Characteristics of the quality measures, incentives, providers, patients, and concurrent interventions probably influenced the results. Study methodology problems such as small sample sizes, selection bias, and inadequate control for confounders were common. Asthma quality of care markers were included in three nonrandomized studies, two of which showed positive results and one of which was negative.
SUMMARY: The data reviewed in this article suggest that pay-for-performance programmes can improve markers of quality, though not always. Even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives as compared with other factors. More and better-designed studies are needed to determine the actual effectiveness of incentives themselves isolated from other factors, circumstances that promote effectiveness, effectiveness relative to other strategies, and cost-effectiveness.
Pay-for-performance (P4P) intents to stimulate both more effective and more efficient health care delivery. To date, evidence on whether P4P itself is an efficient method has not been systematically analyzed.
OBJECTIVE:
To identify and analyze the existing literature regarding economic evaluation of P4P.
DATA SOURCES:
English, German, Spanish, and Turkish language literature were searched in the following databases: Business Source Complete, the Cochrane Library, Econlit, ISI web of knowledge, Medline (via PubMed), and PsycInfo (January 2000-April 2010).
STUDY SELECTION:
Articles published in peer-reviewed journals and describing economic evaluations of P4P initiatives. Full economic evaluations, considering costs and consequences of the P4P intervention simultaneously, were the prime focus. Additionally, comparative partial evaluations were included if costs were described and the study allows for an assessment of consequences. Both experimental and observational studies were considered.
RESULTS:
In total, nine studies could be identified. Three studies could be regarded as full economic evaluations, and six studies were classified as partial economic evaluations. Based on the full economic evaluations, P4P efficiency could not be demonstrated. Partial economic evaluations showed mixed results, but several flaws limit their significance. Ranges of costs and consequences were typically narrow, and programs differed considerably in design. Methodological quality assessment showed scores between 32% and 65%.
CONCLUSION:
The results show that evidence on the efficiency of P4P is scarce and inconclusive. P4P efficiency could not be demonstrated. The small number and variability of included studies limit the strength of our conclusions. More research addressing P4P efficiency is needed.
