Pay for Performance Lacks Evidence of Clear Benefit

Marcia Frellick

January 10, 2017

Pay-for-performance (P4P) programs have not shown that they consistently improve health outcomes in inpatient or outpatient settings, according to the results of a systematic literature review.

Results of the review, published online January 10 in Annals of Internal Medicine, raise concerns about the effectiveness of the incentives at the heart of the Medicare pay revamp under the Medicare Access and CHIP Reauthorization Act (MACRA), which just went into action on January 1.

Aaron Mendelson, BA, from Oregon Health & Science University in Portland, and colleagues looked at 69 studies (58 of them in ambulatory settings) published from June 2007 to October 2016.

They found low-grade evidence that P4P programs in outpatient care may improve process-of-care outcomes over 2 to 3 years, but data on long-term effects were lacking.

They also found that many of the studies that did make a positive link between the incentives and outcomes were done in the United Kingdom, where incentives are larger than those in the United States.

Researchers found low-level evidence that the incentives made little or any difference in changing intermediate health outcomes, such as laboratory measures or blood pressure readings.

In fact, the review found "insufficient evidence to characterize any effect on patient health outcomes."

In hospital settings, "there was low-strength evidence that P4P had little or no effect on patient health outcomes and a positive effect on reducing hospital readmissions," the authors write.

Many of the studies individually found some positive effects, but the effects were small, the authors note, and because of the inconsistency of the studies and their observational design, it was difficult to tie them confidently to P4P.

The authors say that their findings are similar to those of previous studies that found little consistency in P4P improving patient outcomes.

As to why the programs may have little effect, the authors suggest that because they are implemented among other programs, such as decision-support tools, and public reporting and feedback, the benefit from P4P may be harder to tease out.

It's also possible, they say, that current incentives don't have the optimal structure to bring results.

MIPS Takes Effect

In an accompanying editorial, Teryl K. Nuckols, MD, MSHS, from the Division of General Internal Medicine at Cedars-Sinai Medical Center in Los Angeles, California, says lack of evidence that P4P is making a significant difference is particularly important because it is now national public policy with the advent of the Merit-Based Incentive Payment System (MIPS).

He also notes the lack of consistent findings: "Most of the studies had major methodological limitations, such as lack of a control group, and the more rigorous studies reported less favorable findings."

He says uncertainty about incentives will continue with the switch to MIPS.

For one thing, MIPS is a system of both penalties and rewards, while previous studies have focused on rewards. Penalties "tend to have stronger effects on human behavior," Dr Nuckols notes.

Also, MIPS is a complex system and awards incentives 2 years after care is provided, he says, noting that "[s]imple choices and immediate feedback are generally more influential than complex choices and delayed feedback."

Previous studies have also tended to focus on primary care, specifically preventive care (such as influenza shots), so little is known about the incentives in specialty care.

MIPS also offers the option for physicians to qualify for the penalties or rewards alone or as a group, thus giving groups the incentive to exclude physicians with low scores.

It also remains to be seen whether physicians will game the system, such as selecting healthier patients or altering documentation to improve quality scores, he says.

"Clinicians may be deterred not only from treating patients who are sicker or less adherent to treatment recommendations but also from affiliating with clinicians who treat such patients, which could exacerbate socioeconomic disparities in care," he writes.

The researchers' work was funded by the US Department of Veterans Affairs. They have disclosed no relevant financial relationships. Dr Nuckols reports grants from the Collaborative Spine Research Foundation, the American Association of Neuromuscular & Electrodiagnostic Medicine, Insurance and Care New South Wales, and the Agency for Healthcare Research and Quality, outside the submitted work. In addition, a colleague at RAND, Cheryl Damberg, is a coauthor on the paper that the editorial discusses.

Ann Intern Med. Published online January 10, 2017. Study full text, Editorial extract

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