New Study: Pay-for-Performance Not Meeting Goals

Why Don’t P4P Programs Work?

The authors posited three reasons:

1. ”In the era of modern health reform, P4P programs have been implemented and assessed in settings where other effective quality improvement interventions—such as public reporting, audit and feedback, and electronic decision-support tools—may have been deployed. The incremental benefit of P4P may therefore have been more difficult to demonstrate.”

2. “It is possible that P4P programs have not tested the “best” incentive structures and payment mechanisms. Experts have suggested the importance of designing P4P programs using the principles of behavioral economics, in which such factors as payment size, timing, and frequency are believed to have important influences on individual behavior.”

   “Studies of the United Kingdom’s QOF [Quality and Outcomes Framework] found that incentivized process-of-care measures can lead to improvements, especially in the early years of program implementation, but the rate of improvement slowed over time and there was no clear evidence that QOF improved patient outcomes.”

3. “Finally, P4P programs are very complex health system interventions that have been implemented in various ways. We systematically reviewed studies of implementation factors and also conducted interviews with experts in the field of P4P.”

   “Although direct evidence was inadequate to draw strong conclusions, we found that provider buy-in and alignment of measures with organizational goals were likely to be important in sustaining effective programs.”

   “We found that measures that were transparently developed from the evidence base and that were focused on improving clinical processes and patient outcomes rather than measures of efficiency were more likely to be effective.”

   “We also found that the overall number of incentives in place at any one time needs to be carefully considered. Given the evidence that the most substantial gains were consistently seen in areas of poor baseline performance, we suggested that organizations use incentives in the most-needed areas, review measures regularly, and discontinue them after achieving sustained improvements.”

And Then There Are the Unintended Consequences of P4P

The authors of this systematic review also recently published a systematic review of the unintended consequences of P4P. In summary, the authors found:

1. Limited evidence assessing the extent of gaming.
2. No consistent evidence of a negative effect on health disparities.
3. Small evidence of both positive and negative effects on unincentivized measures.<
4. The costs and burden of documentation and reporting requirements associated with P4P programs. A recent survey study found that U.S. health care providers self-report spending about 15 hours per week reporting and interpreting data for measures. That adds up to billions of dollars of opportunity lost cost. The United Kingdom decided to scale back its QOF program after 10 years of experience, in part because of provider concerns and the inconsistency of data demonstrating long-term benefit./li>
5. P4P programs can threaten clinical autonomy.

The Future

Pay-for-performance programs are set in stone, it seems. Medicare Access and CHIP Reauthorization Act is pushing value-based purchasing—which pretty much mandates P4P programs.

The conclusions from these authors is that P4P is unlikely to have large effects or marked differences in patient and health outcomes as compared to the current, complex, multi-faceted system.