Advertisement

Journal of General Internal Medicine

, Volume 33, Issue 7, pp 1155–1166 | Cite as

Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review

  • Karli K. KondoEmail author
  • Jessica Wyse
  • Aaron Mendelson
  • Gabriella Beard
  • Michele Freeman
  • Allison Low
  • Devan Kansagara
Review Paper

Abstract

Background

Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings.

Methods

We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight.

Results

The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants’ views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population.

Discussion

The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.

KEY WORDS

Veterans pay for performance financial incentives implementation performance metrics systematic review 

Notes

Acknowledgements

We would like to acknowledge Rose Relevo for conducting literature searches and also the contributions of our stakeholders and Technical Expert Panel.

Prior Presentation

The contents of this manuscript have not been presented at any conference.

Funding

This project was funded by the US Department of Veterans Affairs, Veterans Health Administration (VHA) ESP Project #05-225.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4444_MOESM1_ESM.docx (162 kb)
ESM 1 (DOCX 161 kb)

References

  1. 1.
    Senate: Veterans' Affairs Committee. S. 2484 (108th Congress): Department of Veterans Affairs Health Care Personnel Enhancement Act of 2004. December 3 2004.Google Scholar
  2. 2.
    Clough JD, McClellan M. Implementing MACRA: Implications for Physicians and for Physician Leadership. JAMA 2016;315(22):2397–2398.CrossRefGoogle Scholar
  3. 3.
    Kondo K, Damberg C, Mendelson A, et al. Understanding the Intervention and Implementation Factors Associated with Benefits and Harms of Pay for Performance Programs in Healthcare. Washington, DC: Department of Veterans Affairs;2015.Google Scholar
  4. 4.
    Kondo KK, Damberg CL, Mendelson A, et al. Implementation processes and pay for performance in healthcare: A systematic review. J Gen Intern Med 2016;31(Suppl 1):61–69.CrossRefGoogle Scholar
  5. 5.
    Mendelson A, Kondo K, Damberg C, et al. The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review. Ann Intern Med 2017;166(5):341–353.CrossRefGoogle Scholar
  6. 6.
    Department of Veterans Affairs. VHA Office of Community Care. Available at https://www.va.gov/purchasedcare/. Accessed 24 March 2017.
  7. 7.
    Commission on Care. Final Report of the Commission on Care. 2016.Google Scholar
  8. 8.
    Higgins J, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. 2011; http://handbook.cochrane.org/. Accessed 24 March 2017.
  9. 9.
    Wells GA, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Available at http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 24 March 2017.
  10. 10.
    Herzog R, Alvarez-Pasquin MJ, Diaz C, Del Barrio JL, Estrada JM, Gil A. Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health 2013;13(1):17.CrossRefGoogle Scholar
  11. 11.
    Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277–1288.CrossRefGoogle Scholar
  12. 12.
    Berkman N, Lohr K, Ansari M, et al. Grading the Strength of a Body of Evidence When Assessing Health Care Interventions for the Effective Health Care Program of the Agency for Healthcare Research and Quality: An Update. 2013. http://www.effectivehealthcare.ahrq.gov/ehc/products/457/1752/methods-guidance-grading-evidence-131118.pdf. Accessed 28 Dec 2016.
  13. 13.
    Petersen LA, Simpson K, Pietz K, et al. Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. JAMA 2013;310(10):1042–1050.CrossRefGoogle Scholar
  14. 14.
    Saini SD, Powell AA, Dominitz JA, et al. Developing and Testing an Electronic Measure of Screening Colonoscopy Overuse in a Large Integrated Healthcare System. J Gen Intern Med 2016;31 Suppl 1:53–60.CrossRefGoogle Scholar
  15. 15.
    Kansagara D, Tuepker A, Joos S, Nicolaidis C, Skaperdas E, Hickam D. Getting performance metrics right: a qualitative study of staff experiences implementing and measuring practice transformation. J Gen Intern Med 2014;29 Suppl 2:S607–613.CrossRefGoogle Scholar
  16. 16.
    Frakt AB, Trafton J, Pizer SD. The association of mental health program characteristics and patient satisfaction. Am J Manag Care 2017;23(5):e129-e137.PubMedGoogle Scholar
  17. 17.
    Hysong SJ, Amspoker AB, Petersen LA. A Novel Method for Assessing Task Complexity in Outpatient Clinical-Performance Measures. J Gen Intern Med 2016;31 Suppl 1:28–35.CrossRefGoogle Scholar
  18. 18.
    Petersen LA, Pietz K, Woodard LD, Byrne M. Comparison of the predictive validity of diagnosis-based risk adjusters for clinical outcomes. Med Care 2005;43(1):61–67.PubMedGoogle Scholar
  19. 19.
    Rosen AK, Chen Q, Shwartz M, et al. Does Use of a Hospital-wide Readmission Measure Versus Condition-specific Readmission Measures Make a Difference for Hospital Profiling and Payment Penalties? Med Care 2016;54(2):155–161.CrossRefGoogle Scholar
  20. 20.
    Prentice J, Legler A, Li D, Pizer SD. Optimizing Access Metrics in the VA. https://www.hsrdresearchvagov/for_researchers/cyber_seminars/archives/1166-notes.pdf .
  21. 21.
    Prentice JC, Davies ML, Pizer SD. Which outpatient wait-time measures are related to patient satisfaction? Am J Med Qual 2014;29(3):227–235.CrossRefGoogle Scholar
  22. 22.
    Urech TH, Woodard LD, Virani SS, Dudley RA, Lutschg MZ, Petersen LA. Calculations of Financial Incentives for Providers in a Pay-for-Performance Program: Manual Review Versus Data From Structured Fields in Electronic Health Records. Med Care 2015;53(10):901–907.CrossRefGoogle Scholar
  23. 23.
    Benzer JK, Young GJ, Burgess JF, et al. Sustainability of quality improvement following removal of pay-for-performance incentives. J Gen Intern Med 2014;29(1):127–132.CrossRefGoogle Scholar
  24. 24.
    Damschroder LJ, Robinson CH, Francis J, et al. Effects of performance measure implementation on clinical manager and provider motivation. J Gen Intern Med 2014;29 Suppl 4:877–884.CrossRefGoogle Scholar
  25. 25.
    Hysong SJ, Khan MM, Petersen LA. Passive monitoring versus active assessment of clinical performance: impact on measured quality of care. Med Care 2011;49(10):883–890.CrossRefGoogle Scholar
  26. 26.
    Hysong SJ, Simpson K, Pietz K, SoRelle R, Broussard Smitham K, Petersen LA. Financial incentives and physician commitment to guideline-recommended hypertension management. Am J Manag Care 2012;18(10):e378–391.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Hysong SJ, Knox MK, Haidet P. Examining clinical performance feedback in Patient-Aligned Care Teams. J Gen Intern Med 2014;29 Suppl 2:S667–674.CrossRefGoogle Scholar
  28. 28.
    Hysong SJ, Best RG, Pugh JA. Audit and feedback and clinical practice guideline adherence: making feedback actionable. Implement Sci 2006;1:9.CrossRefGoogle Scholar
  29. 29.
    Harris AH, Chen C, Rubinsky AD, Hoggatt KJ, Neuman M, Vanneman ME. Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"? J Gen Intern Med 2016;31 Suppl 1:21–27.CrossRefGoogle Scholar
  30. 30.
    Petersen LA, Ramos KS, Pietz K, Woodard LD. Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act. Health Serv Res 2016.Google Scholar
  31. 31.
    Beard AJ, Hofer TP, Downs JR, et al. Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment. Circ Cardiovasc Qual Outcomes 2013;6(1):66–74.CrossRefGoogle Scholar
  32. 32.
    Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP. Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing? Arch Intern Med 2012;172(12):938–945.CrossRefGoogle Scholar
  33. 33.
    Petersen LA, Woodard LD, Henderson LM, Urech TH, Pietz K. Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients? Circulation 2009;119(23):2978–2985.CrossRefGoogle Scholar
  34. 34.
    Saini SD, Vijan S, Schoenfeld P, Powell AA, Moser S, Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ 2014;348:g1247.CrossRefGoogle Scholar
  35. 35.
    Powell AA, White KM, Partin MR, et al. Unintended consequences of implementing a national performance measurement system into local practice. J Gen Intern Med 2012;27(4):405–412.CrossRefGoogle Scholar
  36. 36.
    Powell AA, White KM, Partin MR, et al. More than a score: a qualitative study of ancillary benefits of performance measurement. BMJ Qual Saf 2014;23(8):651–658.CrossRefGoogle Scholar
  37. 37.
    Quinn M, Robinson C, Forman J, Krein SL, Rosland AM. Survey instruments to assess patient experiences with access and coordination across health care settings: available and needed measures. Med Care2017;55 Suppl 7 Suppl 1:S84-s91.CrossRefGoogle Scholar
  38. 38.
    Finley EP, Noel PH, Mader M, et al. Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation. Med Care. 2017;55 Suppl 7 Suppl 1:S61-s70.CrossRefGoogle Scholar
  39. 39.
    Gellad WF, Cunningham FE, Good CB, et al. Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-methods Evaluation. Med Care2017;55 Suppl 7 Suppl 1:S26-s32.CrossRefGoogle Scholar
  40. 40.
    Tsai J, Yakovchenko V, Jones N, et al. "Where's My Choice?" An Examination of Veteran and Provider Experiences With Hepatitis C Treatment Through the Veteran Affairs Choice Program. Med Care. 2017;55 Suppl 7 Suppl 1:S13-s19.CrossRefGoogle Scholar
  41. 41.
    Zuchowski JL, Chrystal JG, Hamilton AB, et al. Coordinating Care Across Health Care Systems for Veterans With Gynecologic Malignancies: A Qualitative Analysis. Med Care. 2017;55 Suppl 7 Suppl 1:S53-s60.CrossRefGoogle Scholar
  42. 42.
    Hysong SJ, SoRelle R, Broussard Smitham K, Petersen LA. Reports of unintended consequences of financial incentives to improve management of hypertension. PLoS One 2017;12(9):e0184856.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply) 2018

Authors and Affiliations

  • Karli K. Kondo
    • 1
    • 2
    Email author
  • Jessica Wyse
    • 1
  • Aaron Mendelson
    • 2
  • Gabriella Beard
    • 1
  • Michele Freeman
    • 1
  • Allison Low
    • 1
  • Devan Kansagara
    • 1
    • 2
  1. 1.Portland VA Health Care System Evidence-based Synthesis ProgramPortlandUSA
  2. 2.Oregon Health and Science UniversityPortlandUSA

Personalised recommendations