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

Abstract

BackgroundPay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.MethodsThe systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.ResultsOne hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.ConclusionsP4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

“…54 These incentives also have a positive eff ect on coordination of care, 55 but no discernible eff ect on equity. 56 Willis-Shattuck and colleagues 57 concluded from their review that fi nancial incentives alone are insuffi cient to motivate health workers in low-income and middleincome countries.…”

The Use of Three Strategies to Improve Quality of Care at a National Level

“…However, the overall effect was small and highly context-specific [16,28,49,61,66,67,72]. Three of four studies of physician-level financial incentives, one study of financial incentives directed toward health administrators, and four of five studies of provider-level financial incentives showed positive improvement in quality [3,9,12,28,33,44,48,64].…”

“…All but one study of pay-for-performance was conducted in the United States [15]. Five systematic reviews [16,49,61,67,72] concluded that pay-for-performance can improve quality, but observed effects were small and nuanced, influenced by other factors including program design and characteristics of the incentive, patients, and clinicians. In one review, appraisal of the most rigorous studies found only a 2-to 4-percentage point improvement [49].…”

“…In one review, appraisal of the most rigorous studies found only a 2-to 4-percentage point improvement [49]. Most pay-forperformance focused on process indicators, which were presumably under direct control of providers and/or the health system [61,72]. In contrast, various factors contributed to patient outcomes, and many, if not most, were not within clinicians' control [66].…”

“…In contrast, various factors contributed to patient outcomes, and many, if not most, were not within clinicians' control [66]. Greater improvement was reported when rewarding process and clinical indicators as compared with patient and efficiency outcomes, respectively [64,66,72]. Stakeholder involvement in design and evaluation of measures, and strong dissemination, further enhanced improvement [16,72].…”