Pay for Performance

McWilliams, J. Michael

doi:10.1001/jama.2022.20945

Cited by 6 publications

(6 citation statements)

References 12 publications

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“…Insofar as chief residents embody aspirational standards espoused by the profession, this study’s findings also suggest that aspects of quality observable to and valued by patients (care experiences) are also observed and valued by physicians. This concordance is consistent with intact physician agency (that physicians will prioritize what patients value when they act on their behalf) and suggests that policies promoting competition among organizations to attract patients may be associated with quality improvements that physicians, too, believe are important. Likewise, competition for physician labor could improve care aspects that patients also value.…”

Section: Discussionmentioning

confidence: 93%

“…We studied the case of chief resident selection, but physicians may also act on this information when placing referrals, consulting peers informally, and choosing from whom to learn and whose recommendations to adopt. When accurately informed, these actions may help promote quality by disseminating best practices and establishing a natural system of rewards (eg, revenue for referrals, reputational benefits, and professional satisfaction from peer recognition) that sidesteps concerns about pay for performance …”

Section: Discussionmentioning

confidence: 99%

“…Whereas physicians may be unaware or distrustful of peers’ high scores on performance measures, they are inherently aware of those whom they perceive to be exemplars. Thus, using the profession’s assessment of physician excellence to identify exemplars may help disseminate best practices within groups by facilitating learning and the application of insights from management science to leverage intrinsic motivation and peer effects in ways that improve quality rather than risk undermining motivation with purely measure-reliant strategies …”

Section: Introductionmentioning

confidence: 99%

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Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Chen

McWilliams

2023

JAMA Intern Med

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ImportancePhysicians’ knowledge about each other’s quality is central to clinical decision-making, but such information is not well understood and is rarely harnessed to identify exemplars for disseminating best practices or quality improvement. One exception is chief medical resident selection, which is typically based on interpersonal, teaching, and clinical skills.ObjectiveTo compare care for patients of primary care physicians (PCPs) who were former chiefs with care for patients of nonchief PCPs.Design, Setting, and ParticipantsUsing 2010 to 2018 Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data (response rate, 47.6%), Medicare claims for random 20% samples of fee-for-service beneficiaries, and medical board data from 4 large US states, we compared care for patients of former chief PCPs with care for patients of nonchief PCPs in the same practice using linear regression. Data were analyzed from August 2020 to January 2023.ExposuresReceiving the plurality of primary care office visits from a former chief PCP.Main Outcomes and MeasuresComposite of 12 patient experience items as primary outcome and 4 spending and utilization measures as secondary outcomes.ResultsThe CAHPS samples included 4493 patients with former chief PCPs and 41 278 patients with nonchief PCPs. The 2 groups were similar in age (mean [SD], 73.1 [10.3] years vs 73.2 [10.3] years), sex (56.8% vs 56.8% female), race and ethnicity (1.2% vs 1.0% American Indian or Alaska Native, 1.3% vs 1.9% Asian or Pacific Islander, 4.8% vs. 5.6% Hispanic, 7.3% vs 6.6% non-Hispanic Black, and 81.5% vs. 80.0% non-Hispanic White), and other characteristics. The Medicare claims for random 20% samples included 289 728 patients with former chief PCPs and 2 954 120 patients with nonchief PCPs. Patients of former chief PCPs rated their care experiences significantly better than patients of nonchief PCPs (adjusted difference in composite, 1.6 percentage points; 95% CI, 0.4-2.8; effect size of 0.30 standard deviations (SD) of the physician-level distribution of performance; P = .01), including markedly higher ratings of physician-specific communication and interpersonal skills typically emphasized in chief selection. Differences were large for patients of racial and ethnic minority groups (1.16 SD), dual-eligible patients (0.81 SD), and those with less education (0.44 SD) but did not vary significantly across groups. Differences in spending and utilization were minimal overall.Conclusions and RelevanceIn this study, patients of PCPs who were former chief medical residents reported better care experiences than patients of other PCPs in the same practice, especially for physician-specific items. The study results suggest that the profession possesses information about physician quality, motivating the development and study of strategies for harnessing such information to select and repurpose exemplars for quality improvement.

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Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Chen

McWilliams

2023

JAMA Intern Med

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“…24,25 Clinicians, health system leaders, and policy experts have voiced concerns that current quality measures fail to adequately account for patient social risk factors. 14,23,[26][27][28][29] However, directly adjusting quality measures for social risk is controversial because it could be perceived as lowering the standard of care or obfuscating poorer outcomes among underserved patients. 30,31 c Positive values represent increased payment adjustments and negative values represent decreased payment adjustments.…”

Section: Discussionmentioning

confidence: 99%

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program

Liu,

Sandhu,

Joynt Maddox

et al. 2024

JAMA

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ImportanceMedicare’s Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown.ObjectiveTo estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments.Design, Setting, and ParticipantsThis cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments.ExposuresHospital Value-Based Purchasing program HEA.Main Outcomes and MeasuresReclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics.ResultsOf 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non–safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non–high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively.Conclusions and RelevanceMedicare’s implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

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“…In this qualitative study, participants indicated that as designed, fee‐for‐service payments for social screening had—and if scaled, would have—relatively little impact on more systematic uptake of social screening and navigation services in CHCs. It is relevant that an ongoing dialogue about financial incentives in medicine has raised the possibility that financial incentives for medical care practices may undermine professionalism 64,65 or health care professionals’ “unique training and intrinsic concern for their patients.” 66 This point resonates in our findings that the CHC staff felt like social care was already part and parcel of their daily activities—and study participants felt that financial incentives as designed were at times incongruent with those activities, whether because the recommended practices were not applicable to all their patients or were unlikely to lead to meaningful changes in patients’ social conditions. That said, changing clinical norms often requires more than reliance on professionalism, even when the new practices are consistent with an organization's mission.…”

Section: Discussionmentioning

confidence: 99%

Community Health Center Staff Perspectives on Financial Payments for Social Care

LOPEZ,

WING,

ACKERMAN

et al. 2023

Milbank Quarterly

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Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee‐for‐service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee‐for‐service payments are unlikely to strongly influence CHC social care practices. ContextA growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients’ social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee‐for‐service payments on clinical teams’ engagement in these activities.MethodsWe interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches.FindingsWe grouped findings into three categories: participants’ awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well.ConclusionsSmall fee‐for‐service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives—e.g., by increasing clinical teams’ awareness of incentives, linking screening to well‐funded social services, and changing incentive amounts to support social care staffing needs—may increase the uptake of social care practices in CHCs.

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Pay for Performance

Cited by 6 publications

References 12 publications

Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program

Community Health Center Staff Perspectives on Financial Payments for Social Care

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