Pay-for-performance programs may be linked to process-of-care improvements in ambulatory settings

1. In ambulatory settings, pay-for-performance (P4P) programs may be correlated with improvements in processes of care.

2. Neither hospital nor ambulatory settings have shown uniform positive correlations for improved health outcomes.

Evidence Rating Level: 1 (Excellent)

Study Rundown: P4P programs provide financial incentives to health care providers and institutions based on performance for certain quality measures. The aim of P4P programs is to motivate health care providers and institutions to reduce unnecessary expenditures and to improve health outcomes, particularly in places such as the United States where the fee-for-service system may be incentivizing service quantity over quality. This systematic review sought to provide updated summary information regarding the effects of P4P. An analysis of 69 studies found that in ambulatory settings, P4P programs may be correlated with improvements in processes of care. However, no settings have shown uniform positive correlations for improved health outcomes. It is uncertain if the lack of consistent positive findings is connected to the heterogeneity in patient population, program design, and incentive targets or if it is due to the unlikelihood of P4P to have considerable effects on health care.

A strength of this study is that the results complement and augment previous reviews, which have also found inconsistent positive correlations for improved patient health outcomes. Limitations of this review include the lack of a large number of methodologically rigorous studies, heterogeneity in program and population characteristics, and restrictions on broad application of study results from other countries to the United States.

Click to read the study in Annals of Internal Medicine

Relevant Reading: Systematic review: Effects, design choices, and context of pay-for-performance in health care

In-Depth [systematic review]: This systematic review used data from select databases, specific Google and PubMed searches, and specific articles from reference lists of pertinent studies, reviews, editorials, and expert recommendations. Using pre-established criteria, 3418 articles were considered for inclusion. Sixty-nine studies were ultimately chosen, including those from countries outside the United States. Of these studies, 11 were in hospital settings, 58 were in ambulatory settings, 52 included process-of-care outcomes, and 38 reported patient outcomes. Low-strength data reveals associations between P4P and short term process-of-care improvements in ambulatory settings. Longer term effects (beyond 2 to 3 years) had limited data. Many of the studies with positive results took place in the United Kingdom, where there are bigger incentives than those in the United States. Data regarding health outcomes was either inconsistent or insufficient. Low-strength evidence suggests that in the hospital setting, there are positive results regarding reductions in hospital admissions and slight or no effect regarding health outcomes.

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