Issues in the Design and Implementation of Pay-for-Performance Program

On September 20, 2011, Gary Young made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (440 KB). Plugin Software Help.

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Slide 1

Issues in the Design and Implementation of Pay-for-Performance Programs

Gary J. Young, J.D., Ph.D.
Professor and Director
Northeastern University Center for Health Policy and Healthcare Research
Boston, MA

Presentation for Agency for Healthcare Research and Quality, Annual Meeting
September 20, 2011

Financial support from the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation Investigator Award for Health Policy Research.

Slide 2

Design and Implementation Issues

Multi-year study of over 70 provider organizations with quality-related incentive arrangements.

• Surveys of Physicians.
• Interviews with senior leaders from physician organizations and hospitals.
• Analysis of Clinical Data.

Slide 3

Design and Implementation Issues

• Selecting unit of accountability.
• Managing provider attitudes toward pay-for-performance program.

Slide 4

Unit of Accountability

• Individuals.
• Organizations.
• Teams (within or across organizations—e.g., ACOs).

Slide 5

Interviews with Senior Leaders from Physician Organizations and Hospitals

• Telephone Interviews and Site Visits.

Setting	# Senior Leaders
Massachusetts	26
California	37
Michigan	10

Slide 6

Interviews with Senior Leaders

General attitudes and issues:

• Quality incentives (better than utilization).
• Adequacy of dollars (new or old money).
• Awareness and involvement of physicians (grass roots vs. system engineering).
• Internal distribution of financial rewards (where individual physicians were not the unit of accountability):
  • $ individual performance on pay-for-performance (P4P) criteria.
  • $ individual performance on non-P4P criteria.
  • $ equally independent of performance.
  • $ retained at group level for investment (unit of accountability issue).

Slide 7

Interviews with Group Practice Executives

"We have a point system, but I would not classify that under the heading of necessarily a quality system. I'd call it more of a participation system. I think the outcome spills over a little into quality because again, the camaraderie and the communication improve and that's always a good thing when PCPs are talking to specialists, interfacing more...."

Slide 8

Incentives and Unit of Accountability

Image: A chart contrasting Efficiency of Incentive vs. Investment in infrastructure is shown.

Slide 9

Provider Attitudes

Theoretical Perspectives:

• Self Determination Theory.
• Professional Control.

Slide 10

Interviews with Senior leaders

"Plans just throw some money in our way and think we will notice and pay attention. They do not seem to understand that our physicians have deep concerns about what strings are attached. We are always worried about the hidden agenda and what a particular incentive opportunity means for our future."

Slide 11

Attitudes and Responsiveness to Financial Incentives

• Study Setting: Physician network (IPA) in Rochester NY.
  • Implemented tournament-style P4P program for diabetes care.
  • > 300 PCPs.
  • Quality measure: Percentage of expected number of diabetic exams/screens (LDL, 2 HbA1c, urinanalysis, eye exam) conducted.
  • Financial incentive: 50 to 150% of withhold payment.
  • Potential payout up to about $3,000 for diabetic component.
• Survey of physicians at Baseline.
  • Approximately 335 physicians surveyed.
  • Approximately 48% response rate.
  • No performance differences between respondents and non-respondents.

Slide 12

Measurement of Attitudes

Five-point, multi-item Likert scales

• Autonomy: "The incentive system interferes with my autonomy for how I care for patients." (reverse scaled)
• Goal importance: "This financial incentive is tied to a quality target that is clinically meaningful for diabetic patients."

Slide 13

Image: A line graph labeled "Overview: Six-Year Trends in RIPA Diabetes Care" is shown.

Slide 14

Image: A line graph labeled "Physician Performance Score for Diabetes Pay-for-Performance, 1999-2004" is shown.

Slide 15

Image: A line graph labeled "Autonomy and Physician Performance" is shown.

Slide 16

Image: A line graph labeled "Goal Importance and Physician Performance" is shown.

Slide 17

Summary Points

• The unit of accountability carries possible tradeoffs between infrastructure investment and power of incentives.
• Provider attitudes toward incentive programs may be an important moderator of an incentive program's success. Attitudes among providers toward same incentive program may vary markedly.
  • Identify providers with negative attitudes.
  • Create opportunities for providers to have input into program design/implementation.