Meeting Quality Measures Doesn't Necessarily Improve Outcomes

Pay-for-performance, or P4P, programs, as currently constructed, may not always result in healthier patients. So says Katie Coleman, M.S.P.H., lead author of a recently published study that examined a performance-based compensation system for providers at a network of federally qualified health centers located in underserved communities throughout Chicago and surrounding suburbs.

Although P4P programs hold promise, they certainly are not the "cure-all" for what ails the American health care system, said Coleman in an interview. She is a research associate at the MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative, in Seattle. Coleman said findings from the study, "The Impact of Pay-for-Performance on Diabetes Care in a Large Network of Community Health Centers," were broadly consistent with those from other current literature -- namely, that in cases where a P4P program is aimed at a chronic condition, physicians' "process measures improve, and outcome measures often don't."

The study, published in the November Journal of Health Care for the Poor and Underserved, focused on hemoglobin A1c testing and HbA1c scores in patients with diabetes. According to the study's abstract, (use the term "pay-for-performance" to search the journal issue's table of contents) the P4P program increased the likelihood that patients received HbA1c testing, but it did not contribute to improved blood sugar control among study patients.

The study involved 46 primary care physicians and 1,166 patients with diabetes. The majority of patients lived below 200 percent of the federal poverty level and were uninsured or covered by Medicaid.

Beginning in January 2004, physicians in the study's P4P program had their base salaries reduced by between 11 percent and 21 percent. However, the program provided them with an opportunity to boost their salaries back up via incentives. For example, FPs were paid $22 per outpatient visit, regardless of a patient's insurance status, and $5 for meeting each quality of care measure covered by the P4P program. After a provider performed enough services to cover his or her base salary for a given month, incentive payments were awarded for each additional outpatient visit and each additional quality measure.

The quality component of the program paid physicians for performing 50 quality of care measures based on a list developed as part of the federal Healthy People 2010 initiative. These measures included administering vaccinations, conducting HIV screening and counseling about smoking cessation. Physicians also received incentive payments for diabetes-related work, such as completing diabetic flow sheets, ordering HbA1c tests and performing foot examinations.

Several findings emerged from the study. For example, the percentage of patients in the study who received two HbA1c tests per year, as recommended by the American Diabetes Association, or ADA, increased from more than 29 percent in 2003 to more than 45 percent in 2004. However, the increase in the percentage of patients receiving guideline-compliant testing did not correlate with an increase in the percentage of patients whose blood sugar was controlled. In fact, the percentage of patients with an average HbA1c score of less than seven declined in 2004 compared with 2003.

Coleman, along with co-authors Kristin Reiter, Ph.D., and Dan Fulwiler, M.A., concluded that the study also highlighted how a P4P payment mechanism should be structured to reward both high-performers and those who show improvement.

"We found that paying physicians to deliver high-quality care on a per-test basis helped the low-performers to improve, and it also rewarded the high-achievers," said Coleman. That's important, she added, because "there's been a lot of debate in P4P circles that if you set a threshold where you're only going to pay out a bonus if 85 percent of a physician's panel gets a certain test, then it only incentivizes the people who are already pretty high-performing." That strategy leaves out the people that really need help at the bottom of the spectrum, she said.

Coleman said the research shows that physician incentives alone are not enough to effect the changes needed to improve patient health.

"The shame is that P4P has been heralded as the silver bullet that will solve all of our health system woes," said Coleman. "But it 'takes two to tango.'" The other piece of any good quality improvement initiative -- and the direction in which health care policy-makers need to refocus their efforts -- is a system "where the patient has to take control and is empowered to manage the illness, especially in the case of a chronic disease that lasts several years, a decade or even a lifetime," Coleman said.