In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston. He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.
In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.
Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.
But, for five measures—chlamydia testing, hemoglobin A1c testing in diabetics, LDL cholesterol testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.
Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.
There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P [pay for performance] has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”
Dr. Pearson suggested two possible explanations for why his study produced only slight evidence of an impact from pay for performance. First, a statewide trend toward quality improvement may have made it difficult to detect any effect of incentives. Alternatively, pay for performance may have been ineffective in Massachusetts, perhaps because the financial incentives were not large enough to motivate physicians.
Money indeed may turn out to be the pressing issue as pay for performance becomes more common. Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.
But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.
“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.”
Ignoring pay for performance won't make it go away, said Dr. Howard B. Beckman, medical director of the Rochester Individual Physician Association. Timothy F. Kirn/Elsevier Global Medical News