Pediatricians in an accountable care organizations who received small incentives to improve quality did so, but not as significantly as doctors employed by a hospital, a new study found.
Results suggest pay-for-performance can work, but not to the degree hoped for by payers increasingly seeking to tie payment to performance. It also shows more work is needed to identify the best design for incentives.
The results, published online by JAMA Pediatrics, examined quality performance across three physician groups, including one group of community doctors who were offered about $40 per patient to meet targets for well-care visits, immunizations, lead screening and other quality measures. Researchers also looked at community doctors who received no incentive and a third group of doctors employed by a hospital who also had no incentives.
Doctors employed by the hospital saw the greatest improvement. Hospital physicians improved more significantly on eight quality measures compared with community doctors who received an incentive.
When compared with community physicians who received no incentive, the doctors who were offered an incentive did better on five quality measures.
"Other investigators have speculated that the size of the incentives, the penetration of the specific insured population in the practice, practice skill at transformation, and the duration of the incentive are all factors that influence the likelihood that incentives can be effective,” the authors wrote.
The findings underscore the challenge that policymakers and the industry face finding ways to tie payment to performance. Research on how best to design incentives is limited and results are mixed, and other factors—such as introduction of electronic medical records—could also play a role.
The authors of the study are Drs. Sean Gleeson and Kelly Kelleher of Partners for Kids in Columbus, Ohio, the ACO that introduced the incentives in the study, and William Gardner, a senior research scientist with the Children's Hospital of Eastern Ontario in Canada. All three called for further research on quality improvement.
Gleeson said the results highlight the need for providers to review the success of programs. "We need more than good intentions," he said. "We need good outcomes."
Incentives are one tool, but not the only way to accelerate performance improvement. The study examined incentive payments used in 2012 and 2013. The ACO has since started to test new incentive designs with larger and more targeted incentive payments, Gleeson said. The new incentives seek to target care to those most in need. The ACO has also expanded use of nonfinancial incentives to bolster performance, including quality-improvement support, he said.
Uneven results among doctors who received incentives may also be attributable to some measures over which physicians have less control, he said.
Employed hospital physicians may have benefited from clinical decision support from electronic medical records or other hospital quality-improvement efforts, they wrote. Hospital-based physicians also saw the largest performance gains where results were weakest at the start.
