Pay-for-performance incentive programs are commonplace now among many health care payers. A new study out of California reports on the effect of the frequency of bonus payments on clinician quality improvement.
Pay-for-performance (P4P) initiatives rest on the premise that quality in patient care can be improved by providing incentives to clinicians to improve particular metrics (called process and outcome measures) relevant to patients’ health status. Prior research has clearly demonstrated that clinicians can improve tobacco cessation counseling rates and other measures that benefit patients as a result of incentive payments; other studies suggest that current P4P initiatives should put even more risk-reward into the hands of physicians.
The current study is a randomized, unblinded trial comparing the frequency of P4P bonus payments on the change in quality measures. The study investigates physicians practicing in multi-specialty groups in California. Both groups received quality report cards on a quarterly basis; this practice had been in effect prior to initiation of the study. Individual physicians (internists and family practice doctors) were randomized to receive bonus payments (up to $5,000 per year) either on a quarterly or annual basis.
One hundred twenty-four (124) physicians completed the study. Analysis of quality reporting data demonstrated a slow upward trend in composite quality scores in both groups. This trend was not statistically significant. Likewise, there was no statistical difference between the annual- and quarterly- bonus groups in terms of overall change in quality scores. The average bonus amount, which was $2,868, did not differ between the two groups.
The authors of this study correctly mention a major limitation; researchers were unable to conduct an additional comparison investigating the effect that the frequency of report cards for the clinicians might have on the change in bonus payments or overall quality scores. The review board approving this study deemed such a comparison unethical. However, quarterly report cards had been sent to these clinicians prior to the initiation of the study and therefore, it should be safe to assume that the observed results are accurate testimony to the ineffectiveness of the frequency of bonus payments to promote changes in quality.
Commentary
Reimbursement for medical care is often done based on the amount of service provided regardless of the quality of the service. A recent movement towards quality improvement has led to many pay-for-performance (P4P) initiatives across the United States and the world.
Multiple studies have shown that incentive payments to physicians can encourage doctors to improve of the quality of patient care as measured by various process measures (such as antibiotics before surgery) and outcome measures (such as rates of surgical site infections). This study suggests that quality is not necessarily affected by the frequency of bonus payment. Physicians tend to improve with adequate informational feedback despite waiting until the end of the year for financial feedback.
As the P4P movement continues forward, payers ought to consider these lessons:
- bonus payments (and penalties) must be significant enough to effect change (some experts suggest upwards of 10% of total compensation)
- feedback on quality must be frequent enough to allow clinicians to change practice patterns
- payments may be made at any frequency without adversely affecting quality
- process and outcome measures must be meaningful and achieve clinician buy-in
- quality measures must be added, changed, and retired as necessary to remain meaningful
- risk adjustment must be adequate to prevent adverse selection of patients by doctors
by
Cedric K. Dark, MD, MPH
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