Researcher sponsored by Rand and Harvard examined a pay-for-performance program in California to determine if it improved quality and also if it disrupted care, which could occur if physicians focused on the incented measures to the detriment of other, unincented aspects of care. (Rand Article) The authors first looked at a single-payer program, which became subsumed in a larger statewide program, using some fancy models and statistics. The single-payer program had little or no impact, but the statewide one, probably since it affected many more patients in a physician’s practice, did appear to improve performance. Larger awards seem to have a bigger effect. There was some suggestion that physicians focused on measures which provided more reward for a relatively smaller effort, and may have diverted resources away for unrewarded or relatively lower rewarded measures. Overall they concluded that quality did not improve compared to that provided by groups not participating in a similar program, nor did it appear to change outcomes.
The second piece of research reported on physician-specific pay-for-performance in a large group practice. (AJMC Article) The program was designed by physicians in the group practice, not by a payer as is more typical, and the primary question was whether a group-level or physician-specific incentive worked better. The research looked at 9 clinical outcome and process measures. After the physician-specific incentive was implemented performance improved and improved at a faster rate than in the years before it was implemented. Compared to two physician groups with only group-level incentives, the groups with doctor-specific ones appeared to have better performance.
In the third study, researchers examined the effect of PPO pay-for performance program on diabetes care. (AJMC Article) The researchers looked at rates of testing for glycosylated hemoglobin and low-density lipoprotein cholesterol and on hospitalization rates. They found that patients who saw physicians participating in a pay-for-performance program had higher rates of testing and lower rates of hospitalization. The results were best for patients who had seen a participating physician over several years. Interestingly, they were worse for patients who saw multiple primary care doctors. Another useful result is an apparently clear connection between being tested more frequently and fewer hospitalizations.
There is a growing body of research which provides good evidence to support and improve pay-for-performance programs. One unfortunate aspect of these programs is that they appear to be necessary at all to get physicians to focus on doing the right thing for patients.