Patient Outcomes and Evidence‐Based Medicine in a Preferred Provider Organization Setting: A Six‐Year Evaluation of a Physician Pay‐for‐Performance Program

Abstract

Objective. To determine whether health plan members who saw physicians participating in a quality-based incentive program in a preferred provider organization (PPO) setting received recommended care over time compared with patients who saw physicians who did not participate in the incentive program, as per 11 evidence-based quality indicators. Data Sources/Study Setting. Administrative claims data for PPO members of a large nonprofit health plan in Hawaii collected over a 6-year period after the program was first implemented. Study Design. An observational study allowing for multiple member records within and across years. Levels of recommended care received by members who visited physicians who did or did not participate in a quality incentive program were compared, after controlling for other member characteristics and the member's total number of annual office visits. Data Collection. Data for all PPO enrollees eligible for at least one of the 11 quality indicators in at least 1 year were collected. Principal Findings. We found a consistent, positive association between having seen only program-participating providers and receiving recommended care for all 6 years with odds ratios ranging from 1.06 to 1.27 (95 percent confidence interval: 1.03-1.08, 1.09-1.40). Conclusions. Physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether or not a patient receives high quality, recommended care.Key Words. Physician incentive plans, quality indicators, evidence-based medicine 2140Within the past decade, several Institute of Medicine (IOM) reports have recommended quality-based incentive programs as effective tools to improve quality of care (Kohn, Corrigan, and Donaldson 2000; IOM 2001;Corrigan, Eden, and Smith 2002). In response, many health plans, as well as the Centers for Medicare and Medicaid Services (CMS), have turned their focus to measures that evaluate physician performance in various aspects of care quality such as patient satisfaction and processes of care (CMS 2003;Casalino et al. 2003;Webber 2005). While the programs have produced an abundance of anecdotal evidence suggesting that performance-based reimbursement can affect physician behavior (Morrow, Gooding, and Clark 1995;Fairbrother et al. 1999;Forsberg, Axelsson, and Arnetz 2001;Amundson et al. 2003;Roski et al. 2003), the majority of the programs were implemented in a health maintenance organization (HMO) setting (Levin-Scherz, DeVita, and Timbie 2005; Rosenthal et al. 2005), where evaluation of physician adherence to clinical guidelines is easier to make (Sommers and Wholey 2003), compared with a preferred provider organization (PPO) setting, where responsibility for patient care is more likely to be shared between multiple physicians because patients have freedom to see providers without referral. In addition, HMO plans are more likely to have systematic interventions to improve care processes and outcomes, such as reminders, benefit coverage for screenings, and disease management programs (Cas...

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

“…147 Studies for as long as 6 years show that appropriately selected incentives can maintain physician satisfaction, patient satisfaction, and long-term performance. 148 Incentives also reinforce the office team structure. 149 Oversight is essential to the ultimate success of a patient centered medical home system of care.…”

Pay for Performance in Health Care: Methods and Approaches

“…However, given the limited size of the incentives implemented in P4P to date, one can ask whether evaluation results showing no impact or limited impact of P4P are a fair test of this new approach to provider payment. Indeed, recent evidence has shown more positive effects of P4P, although studies have found that the effect size remains modest in most cases and the largest effects are often for provider organizations and physicians that have started at lower levels of performance Felt-Lisk et al, 2007;Gilmore et al, 2007;Glickman et al, 2007;Grossbart, 2006;. One review suggests that incentives of about 5 percent of total physician earnings are large enough to attract "meaningful attention" from physicians (Young et al, 2007).…”

“…For example, some programs have provided incentives for health care professionals to invest in information technology, implement electronic health records (EHRs), or use EHRs. These programs include the Integrated Healthcare Association, Bridges to Excellence, and the Hawaii Medical Services Association (IOM Board on Health Care Services, 2007; Bridges to Excellence, 2008;Gilmore et al, 2007;McDermott et al, 2006).…”

“…• Physician payments limited to 25 percent of Medicare payments made to physicians for similar cases Folsom et al, 2008;IOM Board on Health Care Services, 2007;Lempert & Yanagihara, 2006;Young et al, 2007. b Bridges to Excellence, 2008;Folsom et al, 2008; IOM Board on Health Care Services, 2007;Young et al, 2007. c Gilmore et al, 2007; IOM Board on Health Care Services, 2007. d Folsom et al, 2008;Young et al, 2007. e Trisolini et al, 2008. f . g CMS, 2009bDavidson et al, 2007;Glickman et al, 2007;Grossbart, 2006;.…”

“…The Hawaii Medical Service Association started its P4P program in 1999, making it one of the longest running programs in the US (Gilmore et al, 2007;IOM Board on Health Care Services, 2007). It provides some of the largest incentive payments in the United States, up to 7.5 percent of baseline provider reimbursement.…”