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And One More Thing About Pay-for-Performance

By October 25, 2012Commentary

This seems to be the week for comments on pay-for-performance and public outcomes reporting, two linked quality improvement initiatives.  A Health Affairs article reviews research on results of pay-for-performance programs.   (Health Affairs Article)   The authors categorize pay-for-performance programs into four types, those using process of care measures, those using outcomes measures, those using patient experience measures and those using structure measures, related to providers’ operations.  Many pay-for-performance efforts use a combination of these and cost measures are increasingly a part of the initiatives as well, especially as they evolve to value-based purchasing.   The authors identify over 40 private-sector programs, as well as several Medicare and Medicaid ones.  The PPACA will encourage even more use of this tactic.  Several of the programs have been carefully evaluated.

The programs have mixed results, at best.  The Premier Hospital Quality Demonstration, sponsored by CMS, for example initially showed improvement but a longer term evaluation showed no difference between participating and non-participating hospitals.  The Physician Group Practice Demonstration, on the other hand, seemed to show general and modest improvement.  Concerns about these programs include that providers often don’t fully buy into them, that the incentives may be too low to really motivate providers or even cover the costs of participating and that most of these programs seem to be harmful to providers treating larger numbers of poor patients.  While we generally look at all these heavily promoted health care innovations a jaundiced eye, it is also fair to note that many are in their relative infancy and that it may take time to understand what features need to be incorporated to make the initiatives as effective as possible.  That should be approach that all of these programs are started and operated with–let’s see if this works, and if not, why not and what, if anything, can be done to make it work.

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