Lowest-Scoring PCPs Gain Most in Pay-for-Performance Model

Marcia Frellick

April 07, 2015

Two studies published in the April issue of Health Affairs show areas of promise for pay-for-performance models.

Jessica Greene, PhD, MPH, associate dean for research in the School of Nursing at George Washington University in Washington, DC, and colleagues studied a primary care compensation model at Fairview Health Services, a pioneer accountable care organization (ACO), in Minnesota, in which 40% of providers' pay was based on performance and outcomes.

Using performance data from 2010 and 2012, the researchers found that overall, Fairview's improvement in quality metrics was not greater than the improvement in other comparable Minnesota medical groups.

According to Minnesota Community Measurement data, between 2010 and 2012, Fairview improved by 9 percentage points in vascular care and by 2 percentage points in cancer screening, but its diabetes score dropped by 2 percentage points.

However, the researchers did find that those with the biggest gains were those who had the poorest baseline performance scores: Those who scored in the bottom third on the three quality measures at baseline improved three times more than those in the middle third and six times more than those in the top third.

The researchers also found that the size of the reimbursement was not driving the scores. The vascular care and diabetes care metrics each made up 12% of compensation, but quality of vascular care increased 10 percentage points, whereas quality of diabetes care increased 4 percentage points. The cancer screening metric accounted for half as much compensation (6%) but had the biggest increase (18 percentage points).

"It appears that the complexity of the actions required to improve the metric drove the level of improvement," the authors write.

Because the lowest baseline scorers treated a disproportionately high number of low-income patients, their quality increases narrowed the socioeconomic gap in care, the authors note.

A second study, by Christy Harris Lemak, PhD, and colleagues, examined Blue Cross Blue Shield of Michigan's Physician Group Incentive Program, which uses a fee-for-value approach for primary care physicians. Dr Lemak is a chair of the Department of Health Services Administration at the University of Alabama at Birmingham, and at the time of the study, she was an associate professor in the Department of Health Management and Policy, University of Michigan, Ann Arbor.

The authors found the approach lowered spending by 1.1% from 2008 to 2011 compared with overall spending for adults, and by 5.1% for children. They found the same or improved performance on 11 of 14 quality measures.

Moreover, the researchers observed a significant improvement in participating practices vs nonparticipating practices in three of those measures: adolescent well care, adolescent immunization, and well-child visits at ages 3 to 6 years.

More than 5000 physician practices have remained in the Physician Group Incentive Program. Collectively, these physician practices have established 1422 patient-centered medical homes. Physicians in the program are eligible for a variety of incentives that target improvement on population-based cost measures and evidence-based care.

For example, PCPs can get up to 20% more on office visit fees through PCMH components of the program. They can also get 5% more for an office visit with higher performance on quality measures.

The authors conclude that strengthening and engaging primary care physicians can drive improvement.

"During and since the period of this evaluation," the authors write, "the Physician Group Incentive Program began to motivate communitywide performance improvement through the active engagement of primary care physicians and specialists. In light of the sometimes contentious relationship between hospitals and physicians, we have highlighted an alternative strategy for improving health care value."

Both studies were funded by the Commonwealth Fund. The authors have disclosed no relevant financial relationships.

Health Aff. Published online April 6, 2015. Greene abstract, Lemak abstract


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