Pay for Performance Shows Flaws, as Greater Primary Care Reform Beckons
By Richard Scott
June 5, 2012
Offering physicians financial incentives as a way to boost the quality of healthcare may not be enough motivation to reap significant change, according to a new study that investigated the effects of pay-for-performance measures on physician practices dealing with diabetes patients.
The results of the study, which echo previous studies that show generally lackluster performance improvement in pay-for-performance systems, suggest that a more comprehensive approach is needed to transform the primary care delivery system and witness real change.
Conducted at the University of Toronto, the current study was intended to monitor the effects of the government of Ontario's decision to start reimbursing doctors for meeting benchmarks in diabetes care in 2002. The government agreed to pay out $37 for each patient visit that demonstrated the patient was receiving recommended preventive care, such as eye exams, blood sugar monitoring and cholesterol tests.
An analysis of more than 700,000 patient records over a three-year span (2006-2008) shows that the pay-for-performance incentives delivered little lasting traction, according to the study results, which appeared in Diabetes Care. Just one-quarter of the patients' medical bills included evidence of the incentive payment. And while the number of people who adhered to routine exam recommendations increased from 16 percent in 2000 to 27 percent in 2008, the average annual increase was approximately the same both before and after the incentive was introduced.
Researchers speculate that, in this case at least, the dollar amount of the incentive may not have been large enough to draw doctor's attention and enact widespread change. Additionally, the small-scale scope may not be robust enough to impact the overarching healthcare landscape.
The answer, it seems, may need to be larger.
The Need for Comprehensive Delivery Redesign
This is not the first study on pay-for-performance that has revealed less than stellar results. But what is the reason for a lack of impact for P4P systems?
According to researchers who reviewed the results of the Toronto study, pay for performance may simply not be impactful enough. Researchers say that the more comprehensive primary care shift as encompassed in the medical home model has the potential to delivery wider scale change and real quality improvement.
"We're nibbling around the edges with these kinds of small incentive payments when it comes to improving primary care delivery," said Dr. Michael Parchman, director of the MacColl Center for Health Care Innovation at the Group Health Research Institute in Seattle, in a news report. "We're not addressing the issue of: how do we redesign the way we provide primary care?"
The benefits of comprehensive redesign of primary care, as encapsulated in the medical home model, can be tremendous. One recent demonstration project, for example, reveals how the medical home can cut avoidable emergency department use among high-risk patients. And other long-term studies show how the medical home continually improves care and realizes cost savings over an extended period of time.
"There's a big gap between what we're doing in practice and what the evidence tells us we should be doing," said lead author Dr. Tara Kiran of St. Michael's Hospital in a statement.
"One way of potentially addressing this is, if we pay physicians to try and meet some quality targets, is that one way to close this knowledge-practice gap?"
The answer – in this study, at least – is no. Or not enough. Said Kiran: "[Quality improvement] was not really associated with the incentive code."