The notion of paying health care professionals according to their performance (rather than for throughput or via a capitation model) has gained a deal of traction around the world.
However, a rigorous review reported in Health Policy has found that while the idea has intrinsic appeal, there are many potential pitfalls and unanswered questions.
European researchers reviewed 22 systematic reviews, mainly from studies in primary care, that were published between 2000 and 2011. They found there was not enough evidence to either prove or disprove the effectiveness of pay for performance.
It was more likely to be effective when directed at individual physicians or small groups, and when designed collaboratively with providers, they found.
They said researchers had not paid enough attention to investigating potential unintended consequences, and also observed that most pay for performance systems have not been designed to address inequalities.
The paper is summarised below by Jodie Oliver-Baxter, Research Fellow at PHCRIS, the Primary Health Care & Research Information Service.
Pay for performance: how well does it perform?
Jodie Oliver-Baxter writes:
Pay for performance (P4P) refers to care providers receiving explicit financial incentives based on specific performance measures, often around clinical quality, resource use and patient-reported outcomes.
Over the past 15 years, P4P has become a popular approach to increase efficiency in health care globally with models applied in the US, UK, Canada, New Zealand, Taiwan, Israel and Germany.
The evidence-base for P4P is vast but fragmented due to the focus ranging from preventive to experimental studies, and the omission of other impacts, such as unintended consequences.
This review of 22 systematic reviews sought to provide a structured, comprehensive summary of the evidence of P4P effects and mediating factors.
First, findings suggest that, despite the popularity of the approach, the evidence-base for P4P is insufficient to recommend widespread use without further inquiry.
Second, current evaluations focus predominantly on short-to-intermediate-term impact on clinical processes (e.g. screening and HbA1c levels in individuals with diabetes). Long-term impacts will likely be available in the next few years from research currently underway in the US.
Third, there are several unintended consequences of P4P programs that are under-explored. For example, little is known about the appropriate amount and mix of performance measures that would minimise the risk of providers focusing solely on incentivised performance and diminishing intrinsic motivation.
Similarly, the design features (e.g., the effect of varying the size of the incentive whilst holding other factors constant) require more investigation.
Overall, this article highlights that improving performance via P4P is not as straightforward as it appears.
Preconditions need to be fulfilled in order to ensure P4P yields as much value for money as possible.
These include active provider engagement and support, adequate risk adjustment, transparent information systems for collecting performance data and monitoring undesirable behaviour, and P4P program designs that are tailored specifically to the context/setting.
• Effects of pay for performance in health care: A systematic review of systematic reviews. Eijkenaar F, Emmert M, Scheppach M, & Schöffski O. (2013). Health Policy (In Press). DOI: 10.1016/j.healthpol.2013.01.008
This article, which can be accessed at http://www.sciencedirect.com/science/article/pii/S0168851013000183, features in the 28th February 2013 edition of PHC RIS eBulletin, available at http://www.phcris.org.au/publications/ebulletin/index.php. The eBulletin is designed to inform readers of recently published articles and reports, news items, media releases, upcoming conferences and courses, research grants, scholarships and fellowships, PHC RIS products and services and relevant websites in the primary health care field. Those interested in receiving the weekly eBulletin are invited to subscribe to the free service at http://www.phcris.org.au/mailinglists/index.php.
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