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Measuring Quality in Pay-for-Performance Programs

From ‘One-Size-Fits-All’ Measures to Individual Patient Risk-Reduction Scores

  • Current Opinion
  • Published:
Disease Management & Health Outcomes

Abstract

‘Pay for performance’ is a strategy to improve the quality of healthcare by rewarding physicians who deliver higher-quality service. Pay for performance appears to be a simple and logical solution to address both healthcare quality and cost problems. However, pay for performance in action is often neither simple nor logical. Pay-for-performance programs grade and reward physicians based on whether their patients receive particular healthcare services and achieve certain treatment goals.

We illustrate pay for performance in action by applying a common set of performance measures, physician scoring, and earned incentives to two patient cases. Using ‘one-size-fits-all’ treatment goals to award incentives, pay-for-performance programs may not detect, and thus may discourage, evidence-based care provided to patients with complex medical and social co-morbidities. Targeting and rewarding ideal treatment goals in a patient with complex needs who may never reach incentive-achieving treatment goals may encourage providers to focus on health status improvements that are significantly less than those obtained by complication-risk-reducing care. Applying evidence from the track records of pay-for-performance programs to date, we recommend performance measures and data collection methods to reliably assess physician and healthcare organization behavior, and to avoid provider penalty for non-modifiable patient characteristics of disease severity and self-management capacity. We recommend scoring healthcare quality based on individualized patient risk reduction rather than one-size-fits-all treatment goals, using calculated risk assessments when possible. Performance measures should also be prioritized in scoring to give more weight to measures with stronger evidence to influence risk reduction (e.g. blood pressure control has a stronger impact on reducing cardiovascular events than the influence of glucose control). By re-focusing pay for performance on quality improvement through risk reduction, we aim to prevent patients with complex healthcare needs from becoming financial liabilities to the physician.

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Notes

  1. The HEDIS quality measure of HbA1c <7% is currently under review by the NCQA[42] as a result of the conflicting results of the recent ACCORD (Action to Control Cardiovascular Risk in Diabetes)[43] and ADVANCE (Action in Diabetes and Vascular Disease) trials[44],[45] regarding the cardiovascular outcomes of patients treated in line with intensive glycemic control.

  2. In addition to revisions regarding measures and scoring, we also advocate revisions to incentive plans to directly address barriers to care, such as providing incentives to patients in the form of lower or zero co-pays for healthcare services that have the greatest potential for risk reduction (‘value-based incentive design’). However, this discussion is beyond the scope of this article.

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Acknowledgments

The authors thank Dr Paul Fine, Dr Peter Ubel, and members of the University of Michigan Health Services Research Master Course for reviewing earlier drafts of this manuscript.

No sources of funding were used to assist in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this article.

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Authors and Affiliations

  1. Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA

    Jennifer A. Meddings (Clinical Lecturer)

  2. Department of Internal Medicine, Division of General Medicine, University of Michigan Health System, 300 North Ingalls, Room 7D-10, Ann Arbor, Michigan, 48109-0429, USA

    Laurence F. McMahon Jr (Chief, Division of General Medicine; Professor)

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Correspondence to Jennifer A. Meddings.

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Meddings, J.A., McMahon, L.F. Measuring Quality in Pay-for-Performance Programs. Dis-Manage-Health-Outcomes 16, 205–216 (2008). https://doi.org/10.2165/00115677-200816040-00002

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