Improving Ambulatory Quality of Care — Lessons from Pay-for-Performance
By: Sukyung Chung, PhD and Harold S Luft, PhD
In recent years, improvements in quality of ambulatory care appear to coincide with the growing popularity of pay-for-performance (P4P), or the linking of financial incentives to performance on quality measure results. An often called out example of a P4P program with rapid uptake and substantial improvement in measures of ambulatory quality of care is the Quality and Outcome Framework of the British National Health Service. (1-5) At least one study, however, questions whether the program had any impact on the longstanding trend in improvement. (6) There has been nation-wide improvement in various measures of ambulatory care quality in the U.S. as well, (7) some of which coincide with adoption of various P4P programs.
In the literature, we have not seen well-controlled studies in which the only variable changed is P4P. Most successful P4P programs have not implemented incentive changes in isolation, but rather with other quality improvement initiatives, such as expansion of electronic health records, online personal health records, and disease tracking systems (e.g., disease registry). Such system supports are essential components of the P4P implementation because they allow for tracking performance of quality measures. Simply reporting quality scores could have brought increased attention on the reported quality measures independent of any financial incentives. Moreover, varied quality measure reporting may differentially influence physicians' awareness to the P4P program—some settings provide all the physician scores labeled by physician, while others only give clinicians their own scores relative to the group.
An organizational focus on P4P may enhance the existing performance feedback system, even if the financial incentives are small. Organizations voluntarily participating in P4P experiments may have different "cultures" or leadership with respect to quality improvement. Thus, any observed effect of P4P is in fact a combined effect of simultaneous changes in other influencing factors rather than just the effect of financial incentive itself. Isolating the effect of financial incentives is not only difficult, but also not very informative because it is impossible to implement P4P without such system supports.
Some organizations, on the other hand, have shown outstanding performance in ambulatory quality measures with minimal or no explicit physician-level incentives attached to quality measures. Clinics of Kaiser Permanente, for example, are top ranked in many measures of the Integrated Healthcare Association's California-wide P4P program even though Kaiser does not participate in the incentive program. (8) Similarly, several group practice organizations (e.g., Group Health, Virginia Mason, and Geisinger Health System) perform exceptionally well for such measures without explicit physician level financial incentives associated with the measures. In addition, an impressive improvement in ambulatory quality of care is evident across Veterans Administration (VA) clinics nation-wide in the past decade, (9) which is not attributable to a P4P.
The common factor among these high-quality organizations, with or without physician-specific financial incentives, is an organization-wide advancement in health information technology (HIT) and emphasis on efficient workflow, which together make it easier for physicians to follow clinical guidelines. If the improvement in quality is not directly attributable to financial incentives for individual providers but to other simultaneous system change or reporting of quality, do we still need to offer financial incentives attached to quality measures? Yes, financial incentives may still be needed for many reasons.
First, the extra revenue from P4P programs earmarked for quality improvement could serve as a catalyst for organizations to invest in quality improvement. When distributed at the individual physician level, the financial incentives offered in most P4P programs may not be large enough to change individual physician behavior. Collectively using P4P revenue to implement organizational changes may make it easier for individual physicians to adhere to quality targets (e.g., increasing staff support, development of an automated alert system in the electronic health records).
Second, public reporting of scores on target quality measures, a by-product of P4P, encourages quality improvement. Such reporting may influence reputation, a valuable asset for health care organizations. The direct financial incentives associated with a P4P program also make it easier for the organization to invest in the necessary support systems.
Third, while external bodies may calculate overall quality scores, engaging the providers on an individual basis requires the timely feedback of individual results, which in turn, requires sophisticated information technology infrastructure. Participation in P4P program may have added impetus to organizations implementing HIT and developing tools that allow for monitoring quality and quality improvement. In fact, many P4P programs measure and explicitly reward the implementation of adequate HIT.
Fourth, physicians often resist modifying their practice simply to adhere to externally-implemented quality measures unless those measures are evidence-based and widely acceptable. When adherence to guidelines also results in financial reward, physicians may become more aware of and sensitive about the specifications of the measures and the value of achieving targets. Thus, participation in P4P could increase physicians' engagement with understanding quality measures, and conversely, P4P may have led to the adoption of better (e.g., well-validated) measures to assess performance.
Fifth, large payers or coalition of payers typically initiate P4P to increase the value of their enrollees' health benefits. Increasing quality, lowering costs, or both can enhance value. In its current form, however, P4P focuses predominantly on "quality" rather than cost of care, under the premise of prevention and early intervention reducing the overall health care cost. Such anticipated cost-savings may not be tangible in the short-term. As the scope of measures used in P4P programs expands, increasingly more measures include those that broach the concept of efficiency (e.g., inpatient readmission within 30 days) as a performance target. (10) As the linkages between improved guideline adherence and improved outcomes are sometimes tenuous, P4P measures targeting efficiency may have a greater potential to increase overall health care value than has previously been the case.
In sum, P4P appears to be associated with the improvements in ambulatory care quality in recent years, but such improvements are not necessarily and distinctly due to the financial incentives of P4P. While its causality is not clear due to numerous contemporaneous changes in quality improvement efforts, P4P has arguably increased attention to quality improvement, investment in HIT, development of validated quality measures, and providers' awareness of and adherence to quality standards.
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Author
Sukyung Chung, PhD
Palo Alto Medical Foundation Research Institute, Palo Alto, CA
Harold S. Luft, PhD
Palo Alto Medical Foundation Research Institute, Palo Alto, CA
University of California San Francisco, San Francisco, CA
Disclaimer
The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Quality Measures Clearinghouse™ (NQMC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor, ECRI Institute.
Potential Conflicts of Interest
Drs. Chung and Luft declared no potential conflicts of interest with respect to this expert commentary.
References
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6.Serumaga B, Ross-Degnan D, Avery AJ, et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ. 2011;342:d108.
7.NCQA. State of Health Care Quality. Washington DC: National Committee of Quality Assurance; 2010.
8.California Office of the Patient Advocate. Top medical groups where you live: 2010 ratings by the Integrated Healthcare Association. 2010. Available at: http://www.opa.ca.gov/report_card/topmedicalgroup.aspx . Accessed February 4, 2011.
9.Greenfield S, Kaplan SH. Creating a culture of quality: the remarkable transformation of the Department of Veterans Affairs Health Care System. Annals of Internal Medicine. August 17, 2004 2004 begin_of_the_skype_highlighting 2004 2004 end_of_the_skype_highlighting;141(4):316-318.
10.Integrated Healthcare Association (IHA). Pay for performance: manuals and program operations. 2011. Available at: http://www.iha.org/manuals_operations.html . Accessed February 4, 2011.
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National Quality Measures Clearinghouse | Expert Commentaries: Improving Ambulatory Quality of Care — Lessons from Pay-for-Performance
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