Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review

Abstract

Background The aim of this systematic review is to assess if penalty-based pay-for-performance (P4P) programs are more effective in improving quality and cost outcomes compared to two other payment strategies (i.e., rewards and a combination of rewards and penalties) for surgical care in the United States. Penalty-based programs have gained in popularity because of their potential to motivate behavioral change more effectively than reward-based programs to improve quality of care. However, little is known about whether penalties are more effective than other strategies. Materials and methods A systematic literature review was conducted according to the PRISMA guideline to identify studies that evaluated the effects of P4P programs on quality and cost outcomes for surgical care. Five databases were used to search studies published from 2003 to March 1, 2020. Studies were selected based on the PRISMA guidelines. Methodological quality of individual studies was assessed based on ROBINS-I with GRADE approach. Results This review included 22 studies. Fifteen cross-sectional, 1 prospective cohort, 4 retrospective cohort, and 2 case-control studies were found. We identified 11 unique P4P programs: 5 used rewards, 3 used penalties, and 3 used a combination of rewards and penalties as a payment strategy. Five out of 10 studies reported positive effects of penalty-based programs, whereas evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null. Conclusions This review highlights that P4P programs with a penalty design could be more effective than programs using rewards or a combination of rewards and penalties to improve quality of surgical care.

Impact of reimbursement systems on patient care – a systematic review of systematic reviews

“…In P4P models, six studies report an improvement in resource utilization as an increase in health care services, physician visits and a shorter length of stay [ 20 , 25 , 28 , 32 , 36 , 37 ]. Other reviews come to very heterogeneous results regarding the change in resource utilization after the introduction of P4P models in the following categories: health care and resource utilization, length of stay, readmission rates, process indicators [ 10 , 11 , 27 , 38 ].…”

“…Nine reviews find evidence of improvement with P4P models in these categories: immunization rates [ 35 , 43 ], specific clinical values (e.g., cholesterol, blood pressure, screening rates, birth weight) [ 21 , 39 , 42 , 44 ], quality of care [ 23 , 28 , 45 ]. Heterogeneous outcomes are found in another ten reviews [ 11 , 19 , 20 , 22 , 27 , 36 , 38 , 40 , 46 , 47 ]. Among these, positive as well as negative results are found in patient-related health outcomes [ 19 , 27 ], complication rates [ 38 ], health outcomes, quality of care and screening rates [ 22 , 47 ].…”

“…Heterogeneous outcomes are found in another ten reviews [ 11 , 19 , 20 , 22 , 27 , 36 , 38 , 40 , 46 , 47 ]. Among these, positive as well as negative results are found in patient-related health outcomes [ 19 , 27 ], complication rates [ 38 ], health outcomes, quality of care and screening rates [ 22 , 47 ]. Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ].…”

“…Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].…”

Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures

“…Our study found evidence suggesting improved surgical care related to the implementation of CMS’s national P4P program using a penalty design. Penalties have recently become popular in P4P programs, 51 likely because health care professionals and hospitals are more responsive to losses than gains. 52 Although the incidence of surgical complications is low, the costs of complications are high, and our findings suggest that not paying for hospital-acquired infections might successfully encourage hospitals and health care professionals to improve care for surgical patients.…”