P4P Not Working So Well

Pay-for-performance, which is tightly linked to value-based purchasing, is the notion that you should pay providers based on the outcomes they deliver for you.  They get paid more if they deliver better outcomes.  Depending on the exact measures used, the programs tend to direct providers’ attention to certain aspects of delivering care, potentially at the expense of other aspects.   These programs have been around long enough that there is a fair amount of research on them.  A meta-review in the Annals of Internal Medicine cumulates the lessons of this body of research.  (Annals Article)

The authors found 69 relevant studies, some from outside the US.  There was a lot of variation in the research, from provider setting, to the performance measures to the study design.  Broadly speaking, the outcomes of interest in the research were either care process improvement or actual patient health outcome improvement.  While in the ambulatory care setting there were a few positive studies in regard to processes of care and intermediate health outcomes, the better-designed research found no improvements.  Similarly for programs in a hospital setting, little evidence of gains in either care process or quality outcomes was found, including in such standard measures as patient experience of care and mortality.

Value-based purchasing initiatives are in their relative infancy.  It is likely that the maximal design for these programs has not been discovered.  What form should rewards or penalties take, how large should they be, how often should they be imposed, what measures are most accurate in terms of reflecting meaningful outcome improvement; and many other questions should be answered before we can truly evaluate the effectiveness of the concept.  But so far it ain’t lookin’ good.