A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline. Can you get what you pay for? Pay-for-performance and the quality of healthcare providers. Effects of paying physicians based on their relative performance for quality. Early experience with pay-for-performance: from concept to practice. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Paying doctors by salary: a controlled study of general practitioner behaviour in England. Effects of practitioner education, practitioner payment and reimbursement of patients' drug costs on smoking cessation in primary care: a cluster randomised trial.
Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral.
                This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic).
                Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300.
                A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities. Despite the popularity of pay-for-performance (P4P) among health policymakers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care. Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program.
                The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians.
                There were 334 participating primary care physicians in Rochester, New York.
                The design of the study is a retrospective cohort study using pre/post analysis.
                The measurements adhere to 4 diabetes performance measures between 1999 and 2004.
                While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program.
                This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care. The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care.
                To evaluate the impact of a prototypical physician pay-for-performance program on quality of care.
                We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations.
                Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.
                Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.
                Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline. This study tested the effects of two organizational support processes, the provision of financial incentives for superior clinical performance and the availability of a patient (smoker) registry and proactive telephone support system for smoking cessation, on provider adherence to accepted practice guidelines and associated patient outcomes.
                Forty clinics of a large multispecialty medical group practice providing primary care services were randomly allocated to study conditions. Fifteen clinics each were assigned to the experimental conditions "control" (distribution of printed versions of smoking cessation guidelines) and "incentive" (financial incentive pay-out for reaching preset clinical performance targets). Ten clinics were randomized to receive financial incentives combined with access to a centralized patient registry and intervention system ("registry"). Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients' smoking cessation behaviors.
                Patients' tobacco use status was statistically significant (P < 0.01) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition. Patients visiting registry clinics accessed counseling programs statistically significantly more often (P < 0.001) than patients receiving care in the control condition. Other endpoints did not statistically significantly differ between the experimental conditions.
                The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practices and patient behaviors was mixed. Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment. The study aim was to evaluate the impact of the experimental introduction of salaried contracts in England on general practitioner (GP) behaviour and the quality of care. A controlled before-and-after design was implemented involving ten practices of standard contract GPs, paid largely by capitation and fee-for-service, and ten salaried GP practices. Diaries and routinely available data were used to assess GP workload, and patient assessments of the quality of care were obtained by postal questionnaire. GPs in salaried practices spent less time on practice administration but more working out-of-hours and in direct patient care, allowing more patients to be seen. Total list sizes were smaller in salaried compared with standard contract practices, but lists per GP were higher because of staffing policies. Salaried GPs tended to provide shorter consultations compared with standard contract GPs, prescribe in fewer consultations, but referral rates were similar. Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practices and two in standard contract practices. However, none of these differences were statistically significant. To conclude, salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided. To evaluate new strategies to enhance the promotion of smoking cessation in general practice.
                Cluster randomised trial, 2x2 factorial design.
                82 medical practices in Germany, including 94 general practitioners.
                577 patients who smoked at least 10 cigarettes per day (irrespective of their intention to stop smoking) and were aged 36-75 years.
                Provision of a 2-h physician group training in smoking cessation methods and direct physician payments for every participant not smoking 12 months after recruitment (TI, training+incentive); provision of the same training and direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment (TM, training+medication).
                Self-reported smoking abstinence obtained at 12 months follow-up and validated by serum cotinine.
                In intention-to-treat analysis, smoking abstinence at 12 months follow-up was 3% (2/74), 3% (5/144), 12% (17/140) and 15% (32/219) in the usual care, and interventions TI, TM and TI+TM, respectively. Applying a mixed logistic regression model, no effect was identified for intervention TI (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.65 to 2.43), but intervention TM strongly increased the odds of cessation (OR 4.77, 95% CI 2.03 to 11.22).
                Providing cost-free effective drugs to patients along with improved training opportunities for general practitioners could be an effective measure to achieve successful promotion of smoking cessation in general practice.
The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.