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Pay-for-performance in disease management: a systematic review of the literature

Introduction

❶Effect of financial incentives on inequalities in the delivery of primary clinical care in England:

Background

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In converting the cost savings of QIs into provider tariffs, rewards reflect the impact of high performance on cost savings in the system — a tariff design used in the first major Medicare demonstration 48 but yet to be seen in the UK. However, many improvements in quality are difficult to quantify in financial terms, such as programmes to raise patient satisfaction or to target long-term primary prevention.

Furthermore, using expected savings to set incentive levels would represent a significant administrative burden and require frequent re-evaluation as clinical evidence evolves. Many P4P schemes such as AQ have been introduced with an intentionally minimal direct focus on cost savings; the principal objective is often instead to improve and standardise care quality for patients, with any subsequent cost saving superfluous to the general cause.

Setting bonuses proportionate to cost savings automatically places emphasis on the scheme as a method for saving money, rather than for any altruistic reasons, which may lead to disengagement from participants see Provider support for pay for performance. Optimal service provision, from the perspective of a provider, is to continue implementing quality measures until the cost of doing so for one extra patient is equal to these marginal benefits.

Hypothetically, providers would still choose to participate in the absence of a financial bonus, as long as the return from the altruistic component and marginal benefits to patients outweigh the costs.

In reality, however, this perspective would be financially unsustainable, from the perspective of the commissioner at least; all NHS funds have an opportunity cost in terms of the potential health gains foregone in other areas. Evaluating the benefit associated with increased service quality among providers is difficult: In practice, the cost savings and altruistic sentiments resulting from P4P are often unknown or unquantifiable. In a recent evaluation of the CQUIN scheme, although some attempt was made to mirror incentives to effort required or the level of priority assigned to a measure, decisions on reward weightings were taken on an ad hoc, localised basis, rather than with any formalised evidence to hand.

A key consideration in scheme design is whether or not measures should focus on processes or outcomes. Patient outcomes are often driven by factors outside the control of providers; mortality and morbidity rates are likely to be higher in areas of high poverty, with greater disease prevalence and with lower patient education. Process or structure measures are less likely to be influenced by environmental factors outside the control of the provider and so may reduce provider concerns. Some specialties may be more ideally suited to specific measure types, owing to the way in which care is provided and care quality measured.

Some quality measures, such as smoking cessation, have applicability across a number of conditions; often, however, quality measures suffer from a lack of applicability past one or two similar clinical areas. Indicators are therefore often targeted at specific diseases, particularly those with a significant patient population, within which such schemes may have a greater potential impact. P4P is suited to standardised, well-defined procedures; it is less well suited when measures of performance are difficult to define, obtain or evaluate.

For example, patient compliance with lifestyle changes such as diet or exercise would be difficult for a physician to monitor and verify. Quality measures will be most easily monitored and reported at the point at which providers collect appropriate data as part of standard procedure. Providers need to ensure that they are collecting the relevant data for measurement; calculating risk adjustments for patients, for example, may require non-standard, supplementary demographic or clinical information.

In the absence of baseline variability, evidence of provider improvement is less clear. Rewarding care quality in a limited number of measures may lead to a more narrow focus on only incentivised measures or conditions, whereas larger bundles of measures may induce more general improvements in care quality. However, using a large number of measures increases the overall size and burden of the scheme and correlations between indicators are more likely to exist in a larger set, thereby increasing the risk of large gains and losses between participants.

Locally developed measures have the potential benefit of greater relevance to local health needs. Providers can develop P4P schemes aligned to their own long-term QI efforts, with local schemes used to pilot indicators for later use at national level. National measures, however, allow participants to benchmark progress and achievement against other providers and are more likely to represent a cohesive, comparable set of quality standards.

Evidence from the CQUIN evaluation suggests that, although local contribution to quality measures was considered vital to the success of the scheme, frontline clinicians were rarely encouraged to involve themselves in the development of CQUIN goals and the technical design may have been better suited as a centrally directed initiative.

The significant resource requirements of unusual patient case mixes are likely to affect achievement potential for P4P participants, with slower improvement rates and lower achievement levels. For example, specialist providers may treat and manage patients with more severe diagnoses and may therefore have greater difficulty meeting certain process and outcomes indicators. Participants in areas with greater poverty will perform less well on outcomes indicators that measure risky behaviours such as smoking and drinking levels.

Low levels of education are likely to affect patient adherence and co-operation, thereby slowing improvements in process measures relying on actions from the patient, such as attending support groups or adhering to medication. Setting risk adjustments across providers creates a method for standardising performance across different population groups. However, risk-adjustment methods represent an additional administrative cost and, for the most part, remain underdeveloped and unsupported by clinicians.

Pay-for-performance schemes often incorporate a system of exclusion reporting for patients considered to be ineligible for receipt of one or more quality indicators such as a contraindication for a particular pharmacological product or opting for palliative care instead of treatment.

Such criteria are seen as important in ensuring that patients are not given unsuitable care and allowing health-care professionals to exercise their clinical judgement without fear of being penalised. Eligibility criteria must, however, be clearly defined in order to avoid providers viewing exclusion reporting as an opportunity to exclude seriously ill or non-compliant patients who would otherwise reduce achievement in quality measures.

Evidence from the QOF suggests that the majority of general practitioners GPs did not participate in unwarranted exception reporting, despite some wide variations in the level of reporting across practices.

The presence of perverse incentives induced by P4P is strongly suggested in surveys of US physicians, 60 particularly when risk adjustments are non-existent or considered inadequate and inaccurate.

Focusing on process or structural measures, rather than final outcomes, should discourage providers from selecting patients based on their predicted response to treatment. Commissioners could monitor for changes in provider case mix following the introduction of P4P or use risk-adjusted bonuses based on relative patient complexity, in order to discourage the exclusion of more severe patients. Both strategies, however, represent a time and cost burden.

Much like the issues encountered in fee-for-service reimbursement systems, participants may be encouraged to overuse incentivised measures for the sake of additional reward unless the scheme is properly monitored and audited. Overall quality of care may decrease, owing to an inefficient redistribution of investment between indications resulting from P4P incentives.

One study claims systematic effort diversion present in QOF, 42 whereas another, conversely, notes a relative absence of effort diversion, instead identifying substantial positive spillover effects see Positive spillover effects within the same policy. Some QI measures have the potential to bring broader quality changes to non-incentivised conditions or aspects of care.

A US P4P scheme incentivising completion of measures for diabetes patients under a managed care programme encouraged the rollout of the measures to patients across all health plans, despite the absence of an incentive provision for such patients. A number of P4P schemes include a reporting element, enabling internal staff and external stakeholders to view provider performance. An effectively designed public reporting initiative can have significant effects on commissioner and provider behaviours, even in the absence of a monetary incentive, 64 and can also act as a useful preparatory tool for providers that are new to a P4P scheme.

However, much like a reward scheme, performance reporting carries a risk of unintended consequences, such as gaming the system and patient selection. Indeed, physicians often react more negatively to a P4P scheme that includes external reports, with greater concern placed on the quality of the data and measurement.

Public reports may also be difficult to interpret for their intended audience. Composite scores and statistical and clinical derivations of provider achievement may hinder the use of public reports as decision-making tools for patients. Regarding the use of reporting procedures as a complement to financial incentives, provision of bonuses allows participants to further invest in QI, and may therefore accelerate changes in care above that achievable with performance reporting alone.

However, although praise may increase motivation, the relationship between feedback and performance is complex, with feedback that supplies the correct solution more effective at improving performance than praise. The source of funding for P4P schemes has implications on how providers view such programmes. Withhold schemes encourage the view that high-quality care should be standard practice, rather than an action warranting additional rewards. However, they may also encourage the view that P4P acts as a way for commissioners to hold back much-needed funds, a sentiment acknowledged in an evaluation of CQUINs.

Similarly, in a combined reward—penalty scheme the income generated from fines to low performers would be used as bonus monies for high performers.

Expected returns from penalties also need careful calculation in order to avoid owing bonuses greater than available funds see Kahn et al. Measure targets should be based on the capacity of a provider to improve in the subsequent period; although wealthier, highly resourced providers can be set a more challenging target than providers experiencing greater cost constraints, targets should maintain achievability among all participants. For tournament-style schemes, this could mean the grouping of providers based on resource availability, with rewards provided to winners in each group.

For threshold-style schemes, participants may each work within their own set of performance thresholds or, again, may share targets with other similar providers. Nevertheless, targets for all providers should lead to sufficient QIs and, in turn, health benefits so as to justify the opportunity cost of the scheme. However, participants may become aware that targets in a subsequent period are based on current performance and may, therefore, reduce effort levels in the preceding period in order to maintain a lower future target.

Furthermore, if targets do not actively encourage low performers to catch up with higher achievers, performance disparities may become institutionalised across providers. Targets must therefore be based on both the capacity and the relative need of the provider to improve relative to its peers. In the early stages of a P4P scheme, when provider engagement is still in formation, the intense focus on specific procedures of care may be a shock for participants not yet acquainted with the nature of P4P.

Larger schemes require the recruitment of, and support from, a greater number of health-care professionals, which may be difficult to achieve from the outset. The use of a pilot system has therefore been suggested as a valuable method for phasing in P4P initiatives. In addition, baseline data during the piloting period can be used to set benchmarks and performance targets for when the scheme is fully implemented.

Participation in the scheme may be voluntary for a set period, so that those providers requiring additional time to bring internal systems up to requirement need not be penalised in the interim.

Alternatively, participants could be incentivised on quality measure reporting levels alone i. Providers are then able to learn which areas of their infrastructure need investment prior to entering a full P4P scheme.

However, authors of a study into the Physician Quality Reporting Initiative concluded that P4R would act as a useful preparation technique for providers subsequently involved in P4P. The process by which providers join a P4P scheme will affect the ease with which performance can be evaluated. As discussed previously, allowing providers to volunteer to participate in a scheme is likely to attract participation from those who expect to obtain a net benefit from opting in.

In turn, extrapolating performance potential and applying to the non-participating remainder of the provider network may bias a priori estimates upwards. Mandatory participation of all providers, however, removes the ability to compare performance with a control group of non-participants, so that the counterfactual performance across the same time period may be determined. Random selection into a compulsory scheme can instead ensure that the scheme maintains a mixture of providers operating at various levels of baseline performance.

Subsequent achievement in P4P should therefore more accurately reflect the achievement potential of non-participating organisations. Alternatively, limiting performance to a small number of providers, selected on the basis of sharing some common characteristic, creates the ideal basis for a natural experiment.

This is the case with our evaluation and enables us to compare performance in AQ providers in the north-west of England with those in the rest of the country. By observing performance across comparator organisations over the same time period, the relative effects of the P4P scheme may be isolated from national trends in performance. Ensuring that other contemporaneous shocks are accounted for when evaluating performance is vital, as is the ability to gather equivalent performance data from non-participating organisations from baseline onwards.

In the case of AQ, although performance on process measures outside the NHS North West is not routinely available, we obtained outcomes i. Performance in P4P is often quantified by amalgamating achievement on individual indicators into a single composite score. Although methods for developing this score are numerous, two of the most frequent are the composite process score CPS and the appropriate care score ACS. To provide a comprehensive overview of effects of P4P in a broad sense by synthesizing findings from published systematic reviews.

Systematic literature search in five electronic databases for English, Spanish, and German language literature published between January and June , supplemented by reference tracking and Internet searches. Twenty-two reviews contain evidence on a wide variety of effects. Findings suggest that P4P can potentially be cost- effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled the P4P effect from the effect of other improvement initiatives.

Inequalities among socioeconomic groups have been attenuated, but other inequalities have largely persisted. There is some evidence of unintended consequences, including spillover effects on unincentivized care.

Several design features appear important in reaching desired effects. The evaluated aspects of healthcare delivery differed over the studies. The studies showed positive effects of P4P on the quality of care delivered.

In the other study on PIP-DI, physicians were asked to what extent they implemented the nationally established minimum requirements to diabetes care. The study indicates that financial incentives promote better clinical management of diabetes patients: GPs claiming financial incentives were more likely to comply with all requirements than GPs that did not claim incentives [ 37 ].

Also the study that evaluated the effects of WNY-PIP on healthcare quality showed that the majority of the participating physicians improved their average score on process i. The study evaluating the effects of IHA-P4P found that quality improvement efforts, such as P4P schemes, are positively related with improved delivery of clinical processes of care.

The study that evaluated the effects of external incentives, including financial incentives, did not find a significant relationship between receiving a financial reward for scoring well on quality of care measures between organized care management processes.

However, significant relationships were found for other external incentives such as public recognition and better contracts for healthcare quality and organized care management processes [ 39 ]. This systematic literature review presents an overview of P4P schemes that are currently used to stimulate delivery of chronic care through disease management and provides insights into their effects.

P4P schemes are increasingly implemented in the healthcare system to encourage improvements in healthcare quality. The increasing number of implemented P4P schemes has led to a mounting number of studies on the effects of such schemes.

These studies have, however, not specified their results for P4P schemes that are used to stimulate delivery of chronic care through disease management [ 42 - 44 ]. The increasing number of disease management programs that have been implemented over the last years, has urged the need for insight into P4P schemes focusing on the implementation of disease management programs. The included P4P schemes were systematically disentangled according to the dimensions of P4P schemes defined by Conrad and Perry [ 10 ].

This classification is in line with the characterization of P4P schemes of other authors who have recently published their work in this field [e. Systematically describing the P4P schemes facilitated comparison of their characteristics and effects. This process revealed that retrieving complete and up-to-date information about the characteristics of P4P schemes was difficult.

In most papers schemes were not well-described and information given was often dated. Particularly, information about the certainty, motivation, size, frequency, and duration of the P4P schemes was difficult to obtain. The included P4P schemes were rather similar in their goals i. Financial incentives targeting at healthcare providers strived for improvement of quality and continuity of care by stimulating healthcare providers to deliver chronic care through disease management, whereas incentives targeting at health insurers strived for improvement of quality and continuity of care by stimulating health insurers to enroll patients in disease management programs.

We did not identify P4P schemes in combination with financial incentives for patients e. The included P4P schemes mostly stimulated delivery of chronic care through disease management by interventions that can be related to the CCM elements "decision support" and "clinical information system".

This finding can possibly be explained by the fact that interventions related to these CCM elements are mostly implemented before interventions related to the other elements of the CCM [ 13 , 14 ]. Our literature review yielded only five papers that reported studies on the effects of P4P on healthcare quality [ 16 , 30 , 37 - 39 ]. No papers were found that reported studies evaluating the effects of P4P on healthcare costs. Most studies showed positive effects of P4P on the quality of care delivered.

It should, however, be noted that the observed differences between schemes hinders comparability of their effects on healthcare quality and as a consequence drawing conclusions on the effectiveness of P4P to stimulate delivery of chronic care through disease management in general.

It is therefore not possible to determine the characteristics of P4P schemes that may contribute to improved healthcare quality. This is in line with earlier studies that suggest that the effectiveness of P4P schemes is highly variable in terms of e.

It should further be noted, that since our study mainly yielded studies showing positive effects of P4P schemes, publication bias should be taken into account.

Since almost no studies were found showing no effects of P4P, it is difficult to determine the characteristics of P4P schemes that may not affect healthcare quality and healthcare costs. Another issue which complicates drawing conclusions with regard to the effectiveness of P4P, which is also highlighted by other authors, is that P4P schemes are often not solely implemented [i. Also the P4P schemes included in this study were mostly part of a larger scheme of interventions and were simultaneously implemented with other interventions than can be related to elements of the CCM such as patient registries, physician reminders and feedback, and the implementation of evidence-based guidelines and protocols.

It is therefore difficult to determine the isolated effect of P4P on healthcare quality and related costs. Additionally, as also mentioned by Chaix-Couturier et al.

Hence, to interpret the results of the included studies it is also relevant to have information about the healthcare system where the P4P scheme is implemented and the simultaneously implemented interventions and their features. Although the aforementioned issues complicate drawing conclusions with regard to which P4P schemes are most successful, there are some indications for the design characteristics of P4P schemes that may produce the largest effects.

Second, P4P schemes including a blend of individual- and group-level incentives may be more effective than P4P schemes only including individual or only including group-level incentives. Some performance issues can be improved most efficiently through group action, whereas others can be improved most efficiently through individual action [ 10 , 43 , 45 ]. Third, there are indications that P4P schemes rewarding absolute performance may be more effective than schemes rewarding relative performance.

This, in turn, may result into unwillingness of providers to make investments in quality improvement. Moreover, only rewarding top performers may discourage healthcare providers with lower baseline quality to improve their services since for them it is difficult to outperform healthcare providers who already have high baseline quality [ 10 , 21 , 43 , 45 ]. It should, however, be noted that there are also indications that relative performance incentives are more effective in improving healthcare quality since they offer an ongoing incentive for initial high-quality providers to continue to perform well relative to their network [ 21 ].

On the basis of the current literature it is unclear whether these findings also apply to the design of P4P schemes to encourage delivery of care through disease management. Since evidence for the effectiveness of these P4P schemes is scarce, it is recommended to design methodologically sound studies to gain insight into the design characteristics that are most successful. Empirical evidence is necessary to carefully design P4P schemes and to ensure their effectiveness [ 10 , 42 , 43 , 45 ].

It is further recommended to determine the effect of P4P on equity in healthcare. A recent study of Doran et al. It is unknown if P4P schemes used to stimulate delivery of chronic care through disease management will produce similar effects.

It is therefore recommended to include equity in healthcare as an outcome in future studies in this field. When designing P4P schemes to stimulate disease management, it should further be taken into account that P4P schemes may also have negative consequences for the quality of care.

A potential negative effect, also known as the "distortion effect", is the theoretical concern that stimulation of efforts on the measures of healthcare performance included in the P4P scheme may discourage efforts on aspects of healthcare performance that are not included and rewarded by the scheme.

As a result, P4P may result into reduced healthcare quality, rather than into the intended improved healthcare quality [ 16 , 32 ]. Such potential side-effects of P4P should be included in future studies evaluating the effectiveness of P4P schemes. The number of P4P schemes intending to encourage delivery of chronic care through disease management is still limited. Hardly any information is available about the effects of such schemes on healthcare quality and healthcare costs. SdB and JS performed the literature search and selected relevant papers for the review.

All authors analyzed the included papers. All authors read and approved the final manuscript. The authors gratefully acknowledge the involvement of Luqman Tariq at the start of our study. The authors also thank Richard Heijink for his comments on an earlier version of the manuscript. National Center for Biotechnology Information , U. Published online Oct Simone R de Bruin: Received Mar 2; Accepted Oct This article has been cited by other articles in PMC.

Abstract Background Pay-for-performance P4P is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. Methods A systematic PubMed search was performed for English language papers published between and describing P4P schemes related to the implementation of disease management.

Conclusion The number of P4P schemes to encourage disease management is limited. Background Chronic diseases are the leading cause of disability and death in the Western part of the world [ 1 ]. Methods Study design and search strategy A systematic review of the literature was performed for insight into P4P schemes aiming at stimulation of delivery of chronic care through disease management.

Study selection Two reviewers JS and SdB independently reviewed the papers extracted by the search for their relevance by screening their title and abstract. Table 1 Features of P4P schemes and their dimensions. Open in a separate window.

Table 2 General characteristics pay-for-performance schemes. To improve chronic care treatment for diabetes patients 2. To explore effectiveness of financial incentives in improving care for this patient population 3. Improve quality and efficiency of care within the organization with regard to inpatient admissions, radiology, diabetes care, and asthma care. Only P4P scheme for diabetes and asthma care are relevant for our review. Relative, withhold is returned if network: Each measure has an assigned maximum available point value.

Depends on level of performance. Size of rewards changes over time and differs between health plans that participate in Bridges to Excellence. Stimulate provider organizations to consistently demonstrate high levels of quality performance with regard to preventive care, treatment of acute conditions, and treatment of chronic conditions asthma, diabetes, and coronary heart disease through public recognition and financial reward Only financial incentives for chronic conditions are relevant for our review.

Composite score is calculated and then weighted: Physician groups may receive incentive incremental financial payment for scoring in any of the category measures as long as the group scores in the appropriate percentile ranking as determined by the health plan. Each health plan that participates in IHA-P4P scheme determines its own budget and methodology for calculating and distributing payments to physician groups.

Only financial incentives for diabetes and asthma care are relevant for our review. Practices had to become accredited against standards of RACP. Incentives based on performance on broad range of quality indicators which focused on diabetes mellitus, heart failure, coronary artery disease and hypertension, and preventive care.

Absolute and relative Absolute: The portion provided to PGP is divided in cost performance payment fixed payment and quality performance payment.


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performance (P4P), this incentive model is defined in the literature as the “transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target.”.

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Pay for Performance (P4P) Literature Review Matrix Gary L. Freed, MD MPH, Rebecca L. Uren MHSA. Pay for Performance (P4P) Literature Review Matrix Gary L. Freed, MD MPH, Rebecca L. Uren MHSA The Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan.

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Nevertheless, for studies found the choice of quality measures and pay design of the review structure to be crucial for the pay of Pay programs [ performance, ]. Little is known for P4P programs in ophthalmology and the available empirical evidence. Academic literature review on performance-related pay No consensus on the strength of the link between executive pay and company performance comes out of our extensive literature review. Prof Alistair Bruce and Dr Rodion Skvoroda from Nottingham University Business School review the academic literature on executive performance-related pay.