We are coming up to the one-year anniversary of mandatory pay-for-performance, otherwise known as Quality Payment Program from Centers for Medicare & Medicaid Services (CMS).
Approximately 600,000 U.S. clinicians were affected. These were all doctors who care for adults and are paid via fee-for-service (Part B) Medicare insurance.
The complex Quality Payment Program was part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which passed with strong bipartisan support.
Doctors had a choice of two programs:
- Quality Payment Program through the Merit-Based Incentive Payment System (MIPS)—the default track.
- Advanced Alternative Payment Models, such as risk-bearing accountable care organizations.
Again, more than a half a million U.S. doctors were assigned penalties or rewards in all specialties, making it the largest pay-for-performance initiative in history.
How is it going?
Based on Veterans Administration 2017 review of 69 pay-for-performance studies, not well at all.
According to the review’s authors: “Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.”
VA’s Systematic Review of Pay-for-Performance
Pay-for-performance (P4P) programs are designed to reward or penalize health care providers based on performance measures of quality.
Theoretically, P4P should steer provider behavior in ways that improve care quality, reduce unnecessary spending, and improve outcomes.
It’s a compelling notion—particularly when contrasted with fee-for-service models—which have been associated with variable care quality and costs. Say the critics, fee-for-service models incentivize volume over quality.
Do P4P programs improve care?
This systematic review, which was titled: The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review, looked at 69 studies to answer that question.
Its authors, who hail from the VA Portland Health Care System, the Oregon Health & Science University, Portland, Oregon, and the RAND Corporation, Santa Monica, California, were:
- Aaron Mendelson, BA
- Karli Kondo, Ph.D.
- Cheryl Damberg, Ph.D.
- Allison Low, BA
- Makalapua Motúapuaka, BA
- Michele Freeman, M.P.H.
- Maya O’Neil, Ph.D.
- Rose Relevo, MLIS, MS
- Devan Kansagara, M.D., MCR
The Studies in the Review
The researchers reviewed 3,418 titles and abstracts, identified 586 potentially eligible full-text articles, and ultimately included 69 studies.
Of those, 58 were in ambulatory settings, 11 were in hospital settings.
Fifty-two of the studies looked at process-of-care outcomes. Thirty-eight assessed patient outcomes.
One of the difficulties encountered by the authors was the high variability among P4P programs. Programs had varying incentive structures, goals, and contexts. They differed in purposes and targets and many studies focused on chronic conditions in the primary care setting.
The researchers looked at studies from the United Kingdom (27 studies), the United States (17 studies), Taiwan (13 studies), France (3 studies), the Netherlands (3 studies), Canada (3 studies), Australia (1 study), South Korea (1 study), and Italy (1 study).
There were 2 RCTs [randomized controlled trial] and 67 observational studies (10 ITS [interrupted time series] studies, 37 controlled before–after studies, and 20 large uncontrolled before–after studies).
After conducting the review, the authors concluded that P4P programs can improve process-of-care in ambulatory settings but that the evidence of such improvement was weak. Most of the positive studies were conducted in the United Kingdom, where incentives were larger than in the United States.
