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

Abstract

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 25 th 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.

The Theory of Value‐Based Payment Incentives and Their Application to Health Care

“…Similarly, continuous provider progress toward improved value should be rewarded incrementally-rather than based an all-or-none threshold to qualify for any bonus payments for quality or outcomes. Selecting clear, achievable performance targets strengthens incentives for quality improvement (Kiefe et al 2001;Kirschner et al 2012).…”

Patient and Physician Adherence in Hypertension Management

“…Collate and critically review relevant pay-for-performance (P4P) information from multiple countries, including the United States, appropriately acknowledging differing operating characteristics of healthcare systems across countries. [52][53][54][55][56][57][58] Evaluate the national scalability of promising strategies. Also review the role of improvements in processes of care on patient outcomes.…”

“…Kirschner and colleagues noted that "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." 52 Similarly, Lee and Ferris 53 observed that physicians "should not shy away from payment systems that introduce accountability for clinical outcomes," since alternatives could be worse.…”

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“…70,71 An example of a structural defect in health care is the lack of accessibility of care to those who are unable to afford it. On the micro level, the inability of a patient to access a physician' s office that was not wheelchair accessible also would represent a structural impediment.…”

“…69 Action research may be valuable in health care QI and other systems change research and offers significant promise as 1 foundation for intelligent change. [70][71][72][73] Moving Forward: Toward a Model for Quality Improvement…”