• Financial incentives for quality – a review

    I’ve mentioned this before, but it’s worth a whole post. There is actually a full Cochrane review of pay-for-performance for primary care:

    Background: The use of blended payment schemes in primary care, including the use of financial incentives to directly reward ‘performance’ and ‘quality’ is increasing in a number of countries. There are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system-wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care.

    Objectives: The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:

    1. the different types of financial incentives that have improved quality;
    2. the characteristics of patient populations for whom quality of care has been improved by financial incentives; and
    3. the characteristics of PCPs who have responded to financial incentives.

    Search Methods: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet-based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009.

    Selection Criteria:Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures.

    Data Collection and Analysis: Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals.

    I will freely admit I’ve been skeptical of these types of reforms. It’s not that I don’t think quality is important, or that – in theory – paying for quality is better than paying for quantity. My problem is that I think we haven’t yet figured out how to measure quality well in many cases, and the metrics we pick are often too flawed. People can game the system, rather than really improve outcomes.

    Regardless of my views, this review looked for all reasonably well-designed studies looking at the impact of financial incentives for quality of care in primary care practice. There were seven of them. They included a variety of financial mechanisms. Outcomes of interest included smoking cessation, cervical screening, mammography screening, HbA1c, childhood immunizations, chlamydia screening, appropriate asthma medication, and even diabetes outcomes and patients’ assessments of quality. Six of the seven studies found some modest improvements in some outcomes, but certainly not all. One study found no difference at all. Unfortunately, there was plenty of bias in  some of the studies as well. For instance, none of them considered that the physicians who agree to participate in these types of plans are going to be much different than those that do not.

    The table with the results is simply too large to post. But if it’s not behind a paywall, it’s here and it’s Table 1. Go look. You won’t be that impressed.

    The conclusions were these:

    The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.

    I don’t think there’s much more for me to add. Spot on.

    @aaronecarroll

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    • It seems to me that some of these incentives are at odds with efforts to get individuals to take more control of their spending. After all, the need for cervical or chlamydia screening is strongly correlated with behaviors. Admittedly, women can be deluded about the risk factors of their spouses, but I certainly stopped wanting to spend money on STD screening a few years after becoming exclusive with my partner who is now my husband.

      I’ve long thought there’s a tension between what’s best from a public health standpoint (the average person) and what’s best for you, when you know your own risk factors. When you add in “skin in the game,” through high deductible, I’m sure you’re going to get lots of people deciding they really don’t need this or that recommended health item.

    • “My problem is that I think we haven’t yet figured out how to measure quality well in many cases, and the metrics we pick are often too flawed. People can game the system, rather than really improve outcomes.”
      __

      Indeed. These “quality” proxy measures — e.g. PQRS etc — that are really just tabulations of rates of did/did not do process task “X” are pretty weak.
      Finding uniform outcomes measures across the breadth of major cost clinical px’s is going to be a long time coming.

    • While PCP’s, at least in Michigan was, were once rewarded for good quality outcomes, it now starting to imperative to get those funds since reimbursement rates have fallen so low for E&M codes. The medical group I current work for withholds 30% of a provider’s pay, which has to be earned back my meeting various productivity, patient satisfaction and quality measures. Doing individually, it is thought, will increase our organization’s overall quality score, which kick in certain incentives along with being PCMH certified.