Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China.

BACKGROUND: Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD: We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS: Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION: P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

Primary care physician payment mechanisms toward universal health coverage: A study of Iran and selected countries.

BACKGROUND AND AIM: Primary care physician (PCP) payment mechanisms can be important tools for addressing issues of access, quality, and equity in health care. The purpose of the present study is to compare the PCP payment mechanisms of Iran, Canada, Australia, New Zealand, England, Sweden, Norway, Denmark, the Netherlands, Turkey, and Thailand. METHODS: This is a descriptive-comparative study comparing the PCP payment mechanisms of Iran and selected countries in 2020. Data for each country are collected from reliable databases and are tabulated to compare their payment models. Framework analysis is used for data analysis. RESULTS: The results are provided in terms of PCP payment mechanisms, adjusting factor for capitation, reasons for fee-for-service payment, the role of pay-for-performance (PFP) programme, domain and indicators, and reasons for developing PFP in each country. CONCLUSION: The majority of the countries with high UHC service coverage index have applied a mix of PCP payment mechanisms, most of which include capitation and PFP. Moreover, adjusting capitation by factors such as age, sex, and health status will lead to provision of better services to high-risk populations. In recent years, PFP has been paid to Iranian PCPs in addition to salary. Given the various existing models for primary health care in Iran and the increasing burden of chronic diseases, a more appropriate combination of payment mechanisms that create more incentives to provide active and high-quality care should be developed. Also, when developing payment mechanisms, the required infrastructure such as electronic health record should be considered.

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage.

BACKGROUND: Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. METHODS: A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. FINDINGS: Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients' sex with the policy intervention. Few (15%) of the studies controlled for the provider's sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). CONCLUSIONS: There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage.

BACKGROUND: Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage. METHODS: We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender. RESULTS: We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce. CONCLUSIONS: While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.

Incentives to change: effects of performance-based financing on health workers in Zambia.

BACKGROUND: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. METHODS: Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. RESULTS: Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. CONCLUSIONS: In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

Pay for performance of Estonian family doctors and impact of different practice- and patient-related characteristics on a good outcome: A quantitative assessment.

BACKGROUND AND OBJECTIVE: Several practice- and patient-related characteristics are reported to have an influence on a good quality outcome. Estonia started the pay-for-performance (P4P) system for family doctors (FDs) in 2006. Every year the number of FDs participating in P4P has increased, but only half of the FDs achieved good outcome. The aim of this study was to find out which practice- and patient-related characteristics could have an impact on a good outcome. MATERIALS AND METHODS: The study was conducted using the database from the Estonian Health Insurance Fund. All working FDs were divided into two groups (with "good" and "poor" outcomes) according their achievements in P4P. We chose characteristics which described structure (practice list size, number of doctors, composition of FDs list: age, number of chronically ill patients) during the observation period 2006-2012. RESULTS: During the observation period 2006-2012, the number of FDs with a good outcome in P4P increased from 6% (2006) to 53% (2012). The high number of FDs in primary care teams, longer experience of participation in P4P and the smaller number of patients on FDs' lists all have an impact on a good outcome. The number of chronically ill patients in FDs lists has no significant effect on an outcome, but P4P increases the number of disease-diagnosed patients. CONCLUSIONS: Different practice and patient-related characteristics have an impact on a good outcome. As workload increases, smaller lists of FDs patients or increased staff levels are needed in order to maintain a good outcome.

What drives general practitioners in the UK to improve the quality of care? A systematic literature review.

BACKGROUND: In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated. OBJECTIVES: (1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature. METHODS: This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes. RESULTS: 35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition. DISCUSSION: The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care. CONCLUSION: Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.

Physician descriptions of the influence of pay for performance on medical decision-making.

Objectives: To explore physician descriptions of the influence of pay for performance (P4P) programs on their medical decision-making for the delivery of health care through three antecedents of behavior intention-attitude toward program compliance, perceived behavioral control, and subjective norms. Study design/setting: This study utilized a qualitative descriptive research methodology to capture physician descriptions through semi-structured interviews and a focus group. Primary data was collected from actively practicing physicians in the United States with P4P experience. Principal findings: The findings imply that multiple factors influence physicians' attitudes toward program compliance summarized by four primary themes: (a) program compliance and beliefs of physicians in delivering patient care, (b) design, control, and performance motivation, (c) physician performance measurements and the opinions of others, and (d) patient care and compensation program considerations. Conclusions: The findings suggest that physician involvement in the design, implementation, communication, and on-going evaluation of P4P models influence physician behavior. The findings also suggest that physicians are motivated by the delivery of what they believe is good patient care more than by P4P financial incentives. Finally, the most influential voices for physician P4P compliance includes their physician peers and administrators. Outside of the larger societal benefit of P4P compliance, individual family, friends, policymakers, payors, and others have little to no influence on physician decision-making.

Performance payment challenges for family physician program.

CONTEXT: Payment mechanisms are one of the effective tools for achieving optimal results in health system. Pay for performance (P4P) is one of the best programs to enhance the quality of health services through financial incentives. Considering of implementing family physician program in Iran and the P4P system, it is essential to address the challenges of implementing P4P system in the family physician program. AIMS: This study aimed to investigate the challenges of implementation of P4P system in family physician program. SETTINGS AND DESIGN: The qualitative study was carried out at areas covered by Iran University of Medical Sciences in Tehran, Iran. MATERIALS AND METHODS: The semi-structured interview was conducted on 32 key informants in 2019. The sampling method was determined based on purposeful sampling. The topic guide of interviews was experiences in implementing of family physician program and challenges of implementing P4P system. Participants had least 5-year experience in the family physician program. STATISTICAL ANALYSIS USED: A framework analysis was used to analyze the data using the software MAXQDA 10. RESULTS: The current study identified 7 themes, 14 subthemes, and 46 items related to the challenges to successful implementation of P4P systems in the family physician program including family physicians' workload, family physician training, promoting family physician program, paying to the family physician team, assessment and monitoring systems, information management, and the level of authority of family physicians. CONCLUSION: The study results demonstrated notable challenges for successful implementation of P4P system which can helpful to managers and policymakers.

Pay-for-performance challenges in family physician program.

OBJECTIVE: This study was conducted to investigate the challenges faced in the implementation of the pay-for-performance system in Iran's family physician program. STUDY DESIGN: Qualitative. PLACE AND DURATION OF STUDY: The study was conducted with 32 key informants at the family physician program at the Tabriz University of Medical Sciences between May 2018 and June 2018. Method: This is a qualitative study. A purposeful sampling method was used with only one inclusion criterion for participants: five years of experience in the family physician program. The researchers conducted 17 individual and group non-structured interviews and examined participants' perspectives on the challenges faced in the implementation of the pay-for-performance system in the family physician program. Content analysis was conducted on the obtained data. RESULTS: This study identified 7 themes, 14 sub-themes, and 46 items related to the challenges in the implementation of pay-for-performance systems in Iran's family physician program. The main themes are: workload, training, program cultivation, payment, assessment and monitoring, information management, and level of authority. Other sub-challenges were also identified. CONCLUSION: The study results demonstrate some notable challenges faced in the implementation of the pay-for-performance system. This information can be helpful to managers and policymakers.

Perspectives of Physicians in Small Rural Practices on the Medicare Quality Payment Program.

The Centers for Medicare & Medicaid Services (CMS) recently launched its Quality Payment Program (QPP), which considerably changes the way physicians are paid under Medicare. There has been significant concern about the ability of small rural practices to successfully participate in the program. To address these concerns, RAND researchers conducted interviews with physicians in small rural practices on the initial implementation of the QPP in order to understand the flexibility provisions for small rural practices and to inform future federal rulemaking for the QPP. The findings suggest that small rural practices are struggling to participate in the QPP. Interviewees reported frustration with a lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate. Interviewees suggested several changes to the QPP and Medicare policy to improve the ability of small rural practices to participate in the program. These changes included clarifying and specifying program requirements, reducing the frequency of program policy changes, delaying program implementation for small practices, avoiding penalizing small practices that serve vulnerable populations, developing less obtrusive methods for assessing the quality of care of small practices, providing additional information technology support for small rural practices, and enabling greater engagement of rural physicians by policymakers.

Medicare Access and CHIP Reauthorization Act in Small to Medium-Sized Primary Care Practices.

BACKGROUND: Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare (https://www.vahealthinnovation.org/hvh/) perceive their quality incentives under MACRA. METHODS: This study analyzed data from 16 focus-groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus-groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity. RESULTS: The main findings from the focus-groups are: 1) MACRA awareness is relatively higher in independent practices, 2) steps taken toward MACRA differ by practice ownership, and 3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: 1) practices that joined accountable care organizations are taking proactive approaches to MACRA, and 2) independent practices face ongoing challenges. CONCLUSIONS: This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA's requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policy makers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.

Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study.

This study, sponsored by the American Medical Association (AMA), describes how alternative payment models (APMs) affect physicians, physicians' practices, and hospital systems in the United States and also provides updated data to the original 2014 study. Payment models discussed are core payment (fee for service, capitation, episode-based and bundled), supplementary payment (shared savings, pay for performance, retainer-based), and combined payment (medical homes and accountable care organizations). The effects of changes since 2014 in the Affordable Care Act (ACA) and of new alternative payment models (APMs), such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), are also examined. This project uses the same qualitative multiple-case study method as the 2014 study, relying primarily on semistructured interviews with physician practice leaders, physicians, and other observers. Findings describe the challenges posed by APMs, strategies adopted to deal with APMs, the effects of rapidly changing and increasingly complex payment models, and how risk aversion influences physician practices' decisions to engage in new payment models. Project findings are intended to help guide efforts by the AMA and other stakeholders to improve current and future APMs and help physician practices succeed in them.

Details matter: Physician responses to multiple payments for the same activity.

The UK Quality and Outcomes Framework rewards general practices for achieving quality indicators for chronic disease management. Some indicators are multi-rewarded. For example, there are indicators for controlling blood pressure for patients with diabetes and for patients with chronic heart disease. Thus if a patient has diabetes and heart disease the practice is rewarded twice for controlling her blood pressure. Other indicators are singly rewarded: the incentivised activity is only for patients with single specific condition. We compare general practice performance on single and multi-reward indicators. We use a 2005/6-2012/13 panel of over 800 Scottish general practices, control for practice characteristics, practice fixed effects, indicator characteristics (whether the indicator was for measurement, treatment, or intermediate outcome, maximum payment, upper thresholds), condition, and year and cluster on indicators. We find that the proportion of patients with a given condition for whom a quality indicator was achieved was higher, and the proportion who were exception reported was lower, for multi-reward indicators than for single reward indicators. We also exploit the replacement of multi-reward smoking indicators by single reward indicators in 2006/7. Compared to indicators which were always single or always multi-reward, the proportion of the relevant patients for whom the smoking indicators were achieved fell when the smoking indicators were no longer multi-reward. Fine details of pay for performance schemes matter: they affect physician behaviour and patient outcomes.

Provider payment to primary care physicians in China: background, challenges, and a reform framework.

Aim: To provide a framework for provider payment reform for primary care physicians in China. Background: Primary health care is central to health system reform and payment incentives have significant consequences for the equity and efficiency of it. Methods: This paper describes the special payments system for public primary health institutions and the subsequent internal salary remuneration to primary care physicians in China. Based on an analysis of the major challenges, we suggest a reform framework including the pattern of governance, and payments to primary health institutions and employed physicians. Findings: A mixed system of input-based and output-based payments to institutions would probably be appropriate under a long-term and relational contract with the government. It was also advised that internal remuneration is provided by a basic salary plus a bonus based on performance, and an extra-regional allowance. We hope that the results can be used to shift the passive budgeting of in-house staff within the public primary health institutions toward strategic purchasing.

The influence of welfare systems on pay-for-performance programs for general practitioners: A critical review.

While pay-for-performance (P4P) programs are increasingly common tools used to foster quality and efficiency in primary care, the evidence concerning their effectiveness is at best mixed. In this article, we explore the influence of welfare systems on four P4P-related dimensions: the level of healthcare funders' commitment to P4Ps (by funding and length of program operation), program design (specifically target-based vs. participation-based program), physicians' acceptance of the program and program effects. Using Esping-Andersen's typology, we examine P4P for general practitioners (GPs) in thirteen European and North American countries and find that welfare systems contribute to explain variations in P4P experiences. Overall, liberal systems exhibited the most enthusiastic adoption of P4P, with significant physician acceptance, generous incentives and positive but modest program effects. Social democratic countries showed minimal interest in P4P for GPs, with the exception of Sweden. Although corporatist systems adopted performance pay, these countries experienced mixed results, with strong physician opposition. In response to this opposition, health care funders tended to favour participation-based over target-based P4P. We demonstrate how the interaction of decommodification and social stratification in each welfare regime influences these countries' experiences with P4P for GPs, directly for funders' commitment, program design and physicians' acceptance, and indirectly for program effects, hence providing a framework for analyzing P4P in other contexts or care settings.

Impact of pay for performance on behavior of primary care physicians and patient outcomes.

BACKGROUND AND OBJECTIVES: Pay-for-performance is a financial incentive which links physicians' income to the quality of their services. Although pay-for-performance is suggested to be an effective payment method in many pilot countries (ie the UK) and enjoys a wide application in primary health care, researches on it are yet to reach an agreement. Thus, a systematic review was conducted on the evidence of impact of pay-for-performance on behavior of primary care physicians and patient outcomes aiming to provide a comprehensive and objective evaluation of pay-for-performance for decision-makers. METHODS: Studies were identified by searching PubMed, EMbase, and The Cochrane Library. Electronic search was conducted in the fourth week of January 2013. As the included studies had significant clinical heterogeneity, a descriptive analysis was conducted. Quality Index was adopted for quality assessment of evidences. RESULTS: Database searches yielded 651 candidate articles, of which 44 studies fulfilled the inclusion criteria. An overall positive effect was found on the management of disease, which varied in accordance with the baseline medical quality and the practice size. Meanwhile, it could bring about new problems regarding the inequity, patients' dissatisfaction and increasing medical cost. CONCLUSIONS: Decision-makers should consider the baseline conditions of medical quality and the practice size before new medical policies are enacted. Furthermore, most studies are retrospective and observational with high level of heterogeneity though, the descriptive analysis is still of significance.

Paying physician group practices for quality: A statewide quasi-experiment.

This article presents the results of a unique quasi-experiment of the effects of a large-scale pay-for-performance (P4P) program implemented by a leading health insurer in Washington state during 2001-2007. The authors received external funding to provide an objective impact evaluation of the program. The program was unique in several respects: (1) It was designed dynamically, with two discrete intervention periods-one in which payment incentives were based on relative performance (the "contest" period) and a second in which payment incentives were based on absolute performance compared to achievable benchmarks. (2) The program was designed in collaboration with large multispecialty group practices, with an explicit run-in period to test the quality metrics. Public reporting of the quality scorecard for all participating medical groups was introduced 1 year before the quality incentive payment program's inception, and continued throughout 2002-2007. (3) The program was implemented in stages with distinct medical groups. A control group of comparable group practices also was assembled, and difference-in-differences methodology was applied to estimate program effects. Case mix measures were included in all multivariate analyses. The regression design permitted a contrast of intervention effects between the "contest" approach in the sub-period of 2003-2004 and the absolute standard, "achievable benchmarks of care" approach in sub-period 2005-2007. Most of the statistically significant quality incentive program coefficients were small and negative (opposite to program intent). A consistent pattern of differential intervention impact in the sub-periods did not emerge. Cumulatively, the probit regression estimates indicate that neither the quality scorecard nor the quality incentive payment program had a significant positive effect on general clinical quality. Based on key informant interviews with medical leaders, practicing physicians, and administrators of the participating groups, the authors conclude that several factors likely combined to dampen program effects: (1) modest size of the incentive; (2) use of rewards only, rather than a balance of rewards and penalties; (3) targeting incentive payments to the group, thus potentially weakening incentive effects at the individual level.