Despite the popularity of pay-for-performance (P4P) among health policymakers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care.
Using data about births from the perinatal information system (PIS) registered in Montevideo (Uruguay), we estimated the probability of having a Caesarian section delivery, controlled by risk factors and the endogeneity of the choice of hospital. In public hospitals in Montevideo there is a fixed payment system, but in private hospitals this procedure has to be paid for separately. In the former, there is no effect on the doctor's income if he performs a Caesarian, but in the latter there is a positive effect. Empirical evidence shows the probability of a Caesarean section increases with the age of the woman, the presence of eclampsy, pre-eclampsy, previous hypertension, previous Caesarean sections, multiple pregnancies and fetopelvic disproportion, and decreases for multiparous women and women in a public hospital. In fact, the probability of having a Caesarean section in a private institution is almost two times higher than in a public hospital (20% as against 39%). Focusing on women without risk factors, we found that the probability a Caesarian in a public hospital was 11%, but the probability in a private hospital was 25%. We conclude that the remuneration system explains an important part of this difference.
BACKGROUND: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral. METHODS: This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic). RESULTS: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. CONCLUSION: A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.
OBJECTIVE: To evaluate new strategies to enhance the promotion of smoking cessation in general practice. DESIGN: Cluster randomised trial, 2x2 factorial design. SETTING: 82 medical practices in Germany, including 94 general practitioners. PARTICIPANTS: 577 patients who smoked at least 10 cigarettes per day (irrespective of their intention to stop smoking) and were aged 36-75 years. INTERVENTIONS: Provision of a 2-h physician group training in smoking cessation methods and direct physician payments for every participant not smoking 12 months after recruitment (TI, training+incentive); provision of the same training and direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment (TM, training+medication). MAIN OUTCOME MEASURE: Self-reported smoking abstinence obtained at 12 months follow-up and validated by serum cotinine. RESULTS: In intention-to-treat analysis, smoking abstinence at 12 months follow-up was 3% (2/74), 3% (5/144), 12% (17/140) and 15% (32/219) in the usual care, and interventions TI, TM and TI+TM, respectively. Applying a mixed logistic regression model, no effect was identified for intervention TI (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.65 to 2.43), but intervention TM strongly increased the odds of cessation (OR 4.77, 95% CI 2.03 to 11.22). CONCLUSION: Providing cost-free effective drugs to patients along with improved training opportunities for general practitioners could be an effective measure to achieve successful promotion of smoking cessation in general practice.
BACKGROUND: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. OBJECTIVE: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. PARTICIPANTS: There were 334 participating primary care physicians in Rochester, New York. DESIGN: The design of the study is a retrospective cohort study using pre/post analysis. MEASUREMENTS: The measurements adhere to 4 diabetes performance measures between 1999 and 2004. RESULTS: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. CONCLUSIONS: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.
How primary care physicians are remunerated is an important component of healthcare reform debates in Canada. This paper contributes to the policy debate by drawing together the theoretical insights gained from existing economic theory and evidence on how payment schemes affect physicians' behaviour. Several policy implications for the efficient and effective remuneration of physicians emerge from the analysis, as do directions for future research.
CONTEXT: The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care. OBJECTIVE: To evaluate the impact of a prototypical physician pay-for-performance program on quality of care. DESIGN, SETTING, AND PARTICIPANTS: We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations. MAIN OUTCOME MEASURES: Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing. RESULTS: Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments. CONCLUSION: Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline.
Since payment systems for physicians may affect the efficiency of health care service provision, the design of compensation schemes is a major policy concern. According to standard labour economics and agency theory, fee-for-service contracts are likely to induce higher service production than salary contracts and (pure) capitation contracts. Payment systems may also influence service quality and the overall cost control. Despite the obvious policy significance of these issues, the available empirical research is very limited. This paper is an attempt to remedy this situation by addressing the impact of alternative contracts and payment systems on primary care physicians' service supply. The Norwegian primary physician service is an ideal setting for exploring the impact of payment systems. It is a centralised scheme where health services are mostly publicly financed. Until the June 1st 2001, there were two main types of primary care physicians: local government employees remunerated by a fixed salary, and contract physicians mostly financed by fee-for-service payments. We find that physicians with a fee-for-service contract produce a higher number of consultations and other patient contacts than physicians with a fixed salary. This difference is mostly due to longer working hours, but time efficiency is greater as well. Moreover, a part of the difference is due to a selection effect: salaried physicians prefer shorter working hours and prefer to work less intensively. When these and other effects are taken into account, we find that a change from a salary contract to a fee-for-service contract will increase service production by 20-40%.
BACKGROUND: Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. "One stop" and "open access" clinics have been advocated as a way of improving out-patient services. OBJECTIVES: Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. METHODS: General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral. RESULTS: GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0.11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS. CONCLUSIONS: The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.
BACKGROUND: This study tested the effects of two organizational support processes, the provision of financial incentives for superior clinical performance and the availability of a patient (smoker) registry and proactive telephone support system for smoking cessation, on provider adherence to accepted practice guidelines and associated patient outcomes. METHODS: Forty clinics of a large multispecialty medical group practice providing primary care services were randomly allocated to study conditions. Fifteen clinics each were assigned to the experimental conditions "control" (distribution of printed versions of smoking cessation guidelines) and "incentive" (financial incentive pay-out for reaching preset clinical performance targets). Ten clinics were randomized to receive financial incentives combined with access to a centralized patient registry and intervention system ("registry"). Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients' smoking cessation behaviors. RESULTS: Patients' tobacco use status was statistically significant (P < 0.01) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition. Patients visiting registry clinics accessed counseling programs statistically significantly more often (P < 0.001) than patients receiving care in the control condition. Other endpoints did not statistically significantly differ between the experimental conditions. CONCLUSIONS: The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practices and patient behaviors was mixed. Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment.
Despite the popularity of pay-for-performance (P4P) among health policymakers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care.
