Assessment of a pay-for-performance program in primary care designed by target users.

BACKGROUND: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. OBJECTIVE: To assess changes in performance after introducing a participatory P4P program. DESIGN: An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. MAIN OUTCOME MEASURES: Quality indicators for clinical care (process and outcome) and patient experience. RESULTS: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. CONCLUSIONS: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

Experiences of general practices with a participatory pay-for-performance program: a qualitative study in primary care.

The involvement of target users in the design choices of a pay-for-performance program may enhance its impact, but little is known about the views of participants in these programs. To explore general practices' experiences with pay-for-performance in primary care we conducted a qualitative study in general practices in the Netherlands. Thirty out of 65 general practices participating in a pay-for-performance program, stratified for bonus, were invited for a semistructured interview on feasibility, feedback and the bonus, spending of the bonus, unintended consequences, and future developments. Content analysis was used to process the resulting transcripts. We included 29 practices. The feasibility of the pay-for-performance program was questioned due to the substantial time investment. The feedback on clinical care, practice management and patient experience was mostly discussed in the team, and used for improvement plans, but was also qualified as annoying for one GP and for another GP it brought feelings of insecurity. Most practices considered the bonus a stimulus to improve quality of care, in addition to compensation for their effort and time invested. Distinctive performance features were not displayed, for instance, on a website. The bonus was mainly spent on new equipment or team building. Practices referred to gaming and focusing on those aspects that were incentivised ('tunnel vision') as unintended consequences. Future developments should be directed to absolute thresholds, new indicators to keep the process going, and an independent audit. Linking a part of the bonus to innovation was also suggested. The participants thought the pay-for-performance program was a labour-intensive positive breakthrough to stimulate quality improvement, but warned of unintended consequences of the program and the sustainability of the indicator set.

Design choices made by target users for a pay-for-performance program in primary care: an action research approach.

BACKGROUND: International interest in pay-for-performance (P4P) initiatives to improve quality of health care is growing. Current programs vary in the methods of performance measurement, appraisal and reimbursement. One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs. We developed a P4P program in which the target users were involved in decisions about the P4P methods. METHODS: For the development of the P4P program a framework was used which distinguished three main components: performance measurement, appraisal and reimbursement. Based on this framework design choices were discussed in two panels of target users using an adapted Delphi procedure. The target users were 65 general practices and two health insurance companies in the South of the Netherlands. RESULTS: Performance measurement was linked to the Dutch accreditation program based on three domains (clinical care, practice management and patient experience). The general practice was chosen as unit of assessment. Relative standards were set at the 25th percentile of group performance. The incentive for clinical care was set twice as high as the one for practice management and patient experience. Quality scores were to be calculated separately for all three domains, and for both the quality level and the improvement of performance. The incentive for quality level was set thrice as high as the one for the improvement of performance. For reimbursement, quality scores were divided into seven levels. A practice with a quality score in the lowest group was not supposed to receive a bonus. The additional payment grew proportionally for each extra group. The bonus aimed at was on average 5% to 10% of the practice income. CONCLUSIONS: Designing a P4P program for primary care with involvement of the target users gave us an insight into their motives, which can help others who need to discuss similar programs. The resulting program is in line with target users' views and assessments of relevance and applicability. This may enhance their commitment to the program as was indicated by the growing number of voluntary participants after a successfully performed field test during the procedure. The elements of our framework can be very helpful for others who are developing or evaluating a P4P program.

Improving access to primary care: the impact of a quality-improvement strategy.

PROBLEM: Many patients are not satisfied with the accessibility and availability of general practice, and they would like to see improvement. DESIGN: Quality-improvement study with pre-intervention and post-intervention data collection in 36 general practices. SETTING: General practices located in the south of The Netherlands. KEY MEASURES FOR IMPROVEMENT: Patient satisfaction, experiences and awareness; practice information; and experiences of a mystery patient. STRATEGY FOR CHANGE: The practices received feedback about their accessibility and availability compared with data from practices of colleagues. The practices developed practice-based improvement plans using these feedback results. EFFECTS OF CHANGE: Eighty per cent of the improvement plans were completed or almost completed in 5 months. After the intervention, the accessibility by phone within 2 min increased significantly (10% improvement). The practices that designed an improvement plan showed a larger increase (25% improvement) than practices that did not. Patient awareness of an information leaflet and a separate telephone number for emergency calls also significantly increased (29% improvement and 12% improvement) in practices that designed improvement plans. LESSONS LEARNED: Feedback and practice-based improvement plans were a stimulus to work on and to improve accessibility and availability. All practices started improvement plans, but the overall effect of the changes was modest. This may be due to acceptable accessibility and availability before the intervention was introduced and to the time period of 5 months, which seemed to be too short to complete all practice-based improvement plans. The mystery patient was more satisfied with the accessibility than the real patients. This may be related to our concept of accessibility. We learned that adding a mystery patient for data collection can contribute to more objective measurements of practice accessibility than patient questionnaires alone.