Key Points
Question
Does increasing bonus size or adding the behavioral economic principles of social pressure or loss aversion improve pay-for-performance effectiveness among physicians?
Findings
In this randomized clinical trial of 54 physicians and cohort study including 66 physicians and 8188 patients, increased bonus size was associated with improved quality relative to a comparison group, although adding increased social pressure and opportunities for loss aversion did not improve quality.
Meaning
Increasing pay-for-performance bonus sizes may be associated with improved effectiveness, whereas adding the behavioral economic principles of social pressure and loss aversion may not be.
(HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. OBJECTIVE To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. DESIGN, SETTING, AND PARTICIPANTS Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-indifferences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. EXPOSURES Participation in the 3PC system. MAIN OUTCOMES AND MEASURES The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. RESULTS In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, −3.9 percentage points [95% CI, −4.6 to −3.2 percentage points]; P < .
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