Evaluations of Value-Based Purchasing and Pay-for-Performance Demonstrations
The following is a selection of published and unpublished papers and presentations describing evaluations of pay-for-performance (P4P) systems. If you have papers or presentations that you think should be included here, please email them (or links to them) to us.
The Development of a Performance Incentive Program for Hospitals: A Case Study of a Statewide
Pay-for-Performance Program in Maine," by Gino Nalli, Dennis Scanlon, and Douglas Libby,
Health Affairs, 26, no. 3(2007): 817-824.
"A health care coalition in Maine has piloted a performance-based incentive payment program
that creates a single statewide program, based on common standards. Incentive payments were
funded by a hospital’s financial guarantee that was matched by employers. A two-step incentive
allocation methodology differentiates adequate and superior performance. The incentive model is
sufficiently flexible to accommodate different settings and evolving performance standards.
This case study provides useful insights to payers and hospitals that are considering similar
regional initiatives, emphasizing the collaborative context that underscored this venture."
"Does Pay-for-Performance Improve the Quality of Health Care?" by Laura A. Petersen, LeChauncy D. Woodard,
Tracy Urech, Christina Daw, and Supicha Sookanan, Annals of Internal Medicine 145:4, pp. 265-272,
August 15, 2006.
"This paper reviewed empirical studies that assessed the relationship between
explicit financial incentives and the provision of high-quality health care. Thirteen of 17
studies examined the effect of incentives on process-of-care quality measures. Five of the 6
studies of physician-level financial incentives and 7 of the 9 studies of provider group–level
financial incentives found partial or positive associations with measures of quality.
One of the 2 studies of incentives at the payment-system level found a positive effect on access
to care. In all, 4 studies suggested unintended effects of incentives."
"Early Experience With Pay-for-Performance: From Concept to Practice," by Meredith B. Rosenthal,
Richard G. Frank, Zhonghe Li, and Arnold M. Epstein, JAMA 294:14, pp. 1788-1793, October 12, 2005.
"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."
"Public Reporting and
Pay for Performance in Hospital Quality Improvement," Peter K. Lindenauer, et al,
New England Journal of Medicine 356:486-496, February 1, 2007. Also see summary and interview with
authors in "Pay for Performance
Linked to Modest Improvements in Hospital Quality," Medscape
Medical News, February 2, 2007.
"Hospitals engaged in both public reporting and pay for performance achieved modestly greater
improvements in quality than did hospitals engaged only in public reporting. Additional research is
required to determine whether different incentives would stimulate more improvement and whether the
benefits of these programs outweigh their costs."
Development of Medicare Hospital Value-Based Purchasing Plan: Findings from Environmental Scan, by Cheryl L. Damberg, Melony E.S. Sorbero, Stephanie Teleki, and Ateev Mehrotra, the RAND Corporation, prepared for the CMS VBP Plan Development - 1st Listening Session, January 17, 2007. Available here.
"P4P:
Transitional at Best," by Alice G. Gosfield, Managed Care Magazine, January 2005.
"Given the pace of its adoption, the P4P phenomenon clearly has some appeal. There is no
question that it represents a potential major turning point in how health plans can further improve
quality, by treating providers differently and paying them differently based on aspects of quality.
But there are inherent problems with the current P4P approaches. Plans that are serious about moving
the ball will consider other models and develop them collaboratively, particularly with the physicians
whose behavior they seek to change."
"Measuring
Performance For Treating Heart Attacks And Heart Failure: The Case For Outcomes Measurement," by
Harlan M. Krumholz, Sharon-Lise T. Normand, John A. Spertus, David M. Shahian, and Elizabeth H.
Bradley, Health Affairs 26, no. 1 (2007), pp. 75-85.
"To complement the current process
measures for treating patients with heart attacks and with heart failure, which target gaps in
quality but do not capture patient outcomes, the Centers for Medicare and Medicaid Services (CMS)
has proposed the public reporting of hospital-level thirty-day mortality for these conditions in
2007. This paper presents the case for including measurements of outcomes in the assessment of
hospital performance, focusing on the care of patients with heart attacks and with heart failure.
Recent developments in the methodology and standards for outcomes measurement have laid the
groundwork for incorporating outcomes into performance monitoring efforts for these conditions."
"The Impact of Financial Incentives on Quality of Health Care,"
by R. Adams Dudley, Robert H. Miller, Tamir Y. Korenbrot, and Harold S. Luft," Milbank Quarterly,
Vol. 76, No. 4, pp. 649-686, 1998.
"...In theory, positive financial incentives could provide a great stimulus for quality. In
health care, however, because of the difficulty in measuring quality and a lack of correction for
risk, the financial incentives do not encourage health plans to maximize quality. That said, the
quality of clinical outcomes appears to be similar in FFS and HMOs. Differences between FFS and
HMOs that can be documented often relate more to benefits design and coverage decisions than to the
intent of plans to provide high- or low-quality care. It is unlikely that financial incentives for
quality will be created unless risk differences among enrolled populations can be offset. This will
be technically difficult, but is possible, even within high-cost conditions. The correction for
risk differences wil be the most important stimulus for quality, but it should also be tied to
improvements in information systems and agreement on a minimum benefits package, quality reporting
standards, and financial solvency requirements."
"Compliance: Patient Autonomy vs P4P Imperatives," by Wayne J.
Guglielmo, Medical Economics, March 2, 2007.
"While proponents of quality incentives often gloss over the compliance issue, others note that
pay-for-performance could easily lead to several unintended effects, among them the jettisoning
of patients who refuse to follow doctor's orders, ruining his performance score...depending on the
kind of incentive system, the decision to retain nonadherent patients could be costly, especially if
what's being measured are precisely those things that many patients find the most difficult to comply
with. Under such circumstances, doctors' rational economic decision might be to screen prospective
patients, just as insurance companies often do with their prospective enrollees."