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What Happens if Quality of Care Financial Incentives Are Removed?

By September 4, 2018Commentary

For over a decade policymakers have been obsessed with creating quality of care measures and inventing or penalizing providers for the performance on these measures.  This approach has largely succeeded in doing two things.  One is demonstrating better performance on the measures and the second is driving providers crazy with the time and expense involved in trying to comply.  It is unclear that actual patient health and health care outcomes are any better.  So what happens if you take the financial incentives away?  A study published in the New England Journal of Medicine explores this topic.     (NEJM Study)   The authors used a pay-for-performance scheme in the United Kingdom as the test case.  The National Health Service has initiated a large-scale quality performance program in 2004 and the incentives could amount to as much as 25% of provider revenue.  The program has been scaled back and removed altogether in Scotland.  In 2014, 40 of 121 quality indicators lost their financial incentives.  The compared 12 of these indicators with 6 which retained financial incentives. The measures all primarily covered processes, intermediate outcomes and rendering of health advice, and tended to be for chronic diseases.

The trend on 4 of the 12 indicators before removal of the incentives was statistically significant upward and for two it was downward.  Compared to these trends, in the first year following removal of incentives, there was a downward moderate to large reduction in quality “performance” for all 12 indicators, and generally smaller downward reductions in succeeding years.  The reductions ranged from 5.8% for documentation of smoking status to 62.3% for life-style counseling for hypertension patients.  Health advice measures showed much greater declines than did process ones.  On the 6 comparator indicators for which incentives were retained, four showed steady performance and two showed slight declines.  Variation in performance across practices on the quality measures for which incentives were removed also increased.  The declines in performance tended to be greater in practices serving more affluent areas, which would appear to suggest a narrowing of socioeconomic disparity in care.  It should be noted that these changes are in “documented” performance; the physician may still be doing what the measure required but no longer feeling a need to document it.  Physicians may also feel freer to exercise judgment about whether a patient really needs a certain item of care when the physician no longer feels external pressure to comply with some arbitrary measure.  However well-intentioned, it remains unclear that all the effort directed toward quality of care measure compliance has done squat to actually help patients and we should distinguish between training and education of providers on improving health and quality of care and mere check the box following of prescriptive guidelines.

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