Quality, pay for performance - P4P Impact and Quality: Irrational Exuberance?

What: July/August 2008 Health Affairs article, “The Impact of Pay-for-Performance on Health Care Quality in Massachusetts, 2001-2003,” Samuel Pearson, et al, volume 27, No. 4, pages 1167-1776. Study involved 81 Massachusetts physician groups following P4P guidelines and 73 groups who did not. Overall, performance improved by 73%, but no distinguishable differences existed between participating and non-participating groups.

Why: Because P4P has been all the rage as a powerful incentive to persuade doctors to institute and follow quality indicators. Implications are that that P4P may not be end solution for quality that P4P advocates may be suffering from excessive exuberance, that bonuses had no effect on physician performance, and that “Future research is required to determine whether changes in the magnitude, structure, and alignment of P4P incentives can lead to improved care.”


How: By giving doctors financial incentives consisting of bonuses, generally about 5% of total compensation, sometimes as high as 10%, for recording and implementing performance measures.

When: Last ten years, led by California’s Integrated Health Healthcare Association, consisting of collaborating health plans, physician groups, and hospitals, with 40,000 doctors participating.

Where: Wherever health plans offer P4P programs. 150 plans in effect, most notable in regions where managed care dominates, e.g. California, Northwest, upper Midwest, East Coast, heavily populated metropolitan areas anywhere.

Who: Study included 5 commercial health plans contracting with 90% of Massachusetts practicing primary care physicians and performance measures such Hemoglobin A1C testing, br3at cancer screening, diabetic eye exams, LDL-cholesterol screening, diabetic eye exams, and well-child visits. Lead author Steven Pearson, MD, commented, “Unless you look at a control group of some kind, you may be misleading about what’s really happening.” In another study, Oct, 12, 2005, investigators found California physicians did better on only one measure – cervical cancer screening – than a comparison group of Oregon physicians. Says Meredith Rosenthal, MD, lead author of that study, “We actually have remarkably few evolutions that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty. The programs we’ve evaluated over the last five years have been largely unimpressive in their results.”