P4P programs' ability to improve care 'questionable at best'

January 26, 2011 | Molly Merrill, Associate Editor

Suggested Content

BOSTON – The effect that pay-for-performance (P4P) programs have on health outcomes is being questioned by researchers in a new study.

P4P programs provide financial incentives to physicians for the quality of care they provide and patient outcomes. Healthcare information technology is used in these programs to track quality indicators.

A new study published January 26 in the British Medical Journal presents the strongest evidence yet that P4P does not offer any benefit to patients with hypertension, despite the enormous administrative costs required to maintain such a system.

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," says lead author Brian Serumaga, formerly of Harvard Medical School/Harvard Pilgrim Health Care Institute, but now at University of Nottingham Medical School.

Working closely with researchers at Harvard, Nottingham and the University of Alberta in Canada, Serumaga and his colleagues focused on how P4P might affect outcomes in patients with hypertension, a condition where other interventions such as patient education have shown to be very effective.

The United Kingdom implemented a P4P program called "Quality and Outcomes Framework" in 2004. Analyzing data from the UK's Health Improvement Network, a large database of primary care records from 358 UK general practices, the international research team identified 470,725 patients diagnosed with hypertension between January 2000 and August 2007, spanning four years prior, and three years after, P4P was implemented.

The researchers looked at various measures including blood pressures over time, rates of blood pressure monitoring and hypertension outcomes, as well as illnesses.

Analysis showed that even after allowing for a number of variations, there was no identifiable impact on the cumulative incidence of stroke, heart attacks, renal failure, heart failure or mortality in both patients who had started treatment before 2001 and patients whose treatment had started close to the implementation of P4P.

"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care," says senior author Stephen Soumerai, professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best."

[For more information on P4P adoption, see: Progress made on the pay-for-performance front.]

According to Anthony Avery, also of University of Nottingham Medical School, "Doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. These are factors that reach far beyond simple monetary incentives."

"Policymakers sometimes legislate large and expensive policies based on their beliefs without the requisite hard evidence," says Soumerai. "Policy makers in the U.S. and in Canada who are attempting to enact such programs need to think hard about other more effective approaches."

Reader Comments (2)Login to Post a Comment

robforster says: Let the consultants go home

January 27, 2011 | 12:52PM GMT

P4P programs in open large networks have been a gross failure by the data. Sure one would espect the VA and Kaiser P. to do well, but 80% of Americans are not managed by them. Behavioral change is complex and is just not money. Money helps but training,collective motive, experience, anecdote, belief systems, current effective eduction, peer status other than money, clarity of role in the care model, penguin phenomenon-only to mention a few barriers to clinicl process change. Most physicians "play a long with HEDIS" even those there is no believe that they are measuring outsomes but merely PROCESS (check the box) by the bureaucracy. Yes, some docs particularly academicians (wishful thinkers) believe in them because they must--NCQA and our tutors have sold them to us. Just ask any what the 2nd "P" in P4P means and confusion surrounds us. Most are process metrics and not outcomes and it will take some time getting there. Stop this bureaucratic nonsense until we know what we are talking about supported by data.

pjcasey75 says: No performance improvement, no funding for P4P

January 26, 2011 | 5:30PM GMT

Your article says "questionable at best". It seems to me the researcher should have stayed with the more emphatic statement at the outset of the article - "unmistakable".

It's puzzling that a program which, by it's very definition, is supposed to track performance, would not have already concluded the same thing without requiring an external study to uncover this problem.

It also seems pretty obvious that if P4P was designed to improve performance, but doesn't, then funding should cease. As the article mentions, the costs aren't only in terms of the incentives paid (in this case, it would seem there is no reason to pay any incentives, yes?), but probably much more in the administration and tracking of the program.

Even if advocates are reluctant to accept these results, it seems reasonable that any new P4P programs, being self reporting, should be funded with conditional "sunset" clauses - no improvement by 2014 (for example), no more funding.