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P4P and Multiple Chronic Conditions

Do Pay-for-Performance programs help or hurt patients with chronic conditions?

Federal (P4P) programs are rapidly evolving from financial incentives for delivering quality health care to financial penalties for failing to meet quality metrics. This policy shift will have significant consequences for many providers, especially those serving patients with complex health care needs and multiple chronic conditions (MCCs) like diabetes, heart failure, and COPD.

Source: MTSOfan (Flickr/CC)

Source: MTSOfan (Flickr/CC)

People living with MCCs make up nearly one quarter of the U.S. population. As the population ages, this proportion continues to grow, making management of MCCs a critical priority for improving overall quality and lowering costs.

The impact of P4P on patients with MCCs is unclear. Some studies have shown improved outcomes for multiple conditions, while others have found more fragmentation and of patients with less complex health care needs for participation in P4P programs.

A recent study of a diabetes P4P program in Taiwan used claims data to measure the program’s impact on three outcomes: provision of essential services, continuity of care, and health outcomes. Specifically, the study compared patients with and without MCCs (diabetes and high blood pressure) who were enrolled in the program, with a control group of patients who were not.

The results showed that the P4P program increased the number of essential services, improved continuity of care, and reduced the likelihood of hospital admissions or emergency room visits for program enrollees with and without MCCs. These results diminished slightly in year two of the program’s  implementation. Most notable is the finding that P4P improved continuity of care, contradicting a previous study conducted in the UK.

However, the unique characteristics of Taiwan’s health system—national insurance coverage and open access to specialists—must be considered when applying these findings to the U.S.

Policies that recognize differing baselines and social factors that impact health are necessary to ensure that P4P program incentives and penalties align with the practical experiences of providers serving underserved communities and patients with complex health care needs. This is especially true for patients with MCCs.

commentary by Megan Douglas


Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension. This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme. Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63–0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64–0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes. PMID: 25944704 Chen CC. Health Policy Plan. 2015; epub.

Megan Douglas, JD
About Megan Douglas, JD

Megan Douglas is the Associate Director of Health Information Technology Policy in the National Center for Primary Care at Morehouse School of Medicine in Atlanta, GA. She is a licensed attorney and focuses on health policy and its impact on individuals from underserved communities. She was a 2012-13 Health Policy Leadership Fellow under Dr. David Satcher, 16th Surgeon General of the United States. Megan has worked on health policy issues related to neurodevelopmental disabilities, HIV and AIDS discrimination, racial and ethnic health disparities, and individuals identifying as LGBTQ. In her current role, she is looking at the impact of Health Information Technology (HIT) policies on healthcare providers who serve underserved communities and is identifying ways to leverage HIT to improve health outcomes for the underserved. Contact: Website | Facebook | Twitter | Google+ | More Posts

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