Physician-targeted financial incentives and primary care physicians' self-reported ability to provide high-quality primary care

Implementation Processes and Pay for Performance in Healthcare: A Systematic Review

BACKGROUND

Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.

METHODS

We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.

RESULTS

Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.

DISCUSSION

There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.

Impact of Information Technology, Clinical Resource Constraints, and Patient-Centered Practice Characteristics on Quality of Care

Objective:

Factors in the practice environment, such as health information technology (IT) infrastructure, availability of other clinical resources, and financial incentives, may influence whether practices are able to successfully implement the patient-centered medical home (PCMH) model and realize its benefits. This study investigates the impacts of those PCMH-related elements on primary care physicians’ perception of quality of care.

Methods:

A multiple logistic regression model was estimated using the 2004 to 2005 CTS Physician Survey, a national sample of salaried primary care physicians (n = 1733).

Results:

The patient-centered practice environment and availability of clinical resources increased physicians’ perceived quality of care. Although IT use for clinical information access did enhance physicians’ ability to provide high quality of care, a similar positive impact of IT use was not found for e-prescribing or the exchange of clinical patient information. Lack of resources was negatively associated with physician perception of quality of care.

Conclusion:

Since health IT is an important foundation of PCMH, patient-centered practices are more likely to have health IT in place to support care delivery. However, despite its potential to enhance delivery of primary care, simply making health IT available does not necessarily translate into physicians’ perceptions that it enhances the quality of care they provide. It is critical for health-care managers and policy makers to ensure that primary care physicians fully recognize and embrace the use of new technology to improve both the quality of care provided and the patient outcomes.