Primary care clinicians’ perspectives about quality measurements in safety-net clinics and non-safety-net clinics

Abstract

BackgroundQuality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition’s Quality Measurement Enhancement Project sought to collect data from primary care providers’ (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs’ perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.MethodsQualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.ResultsThree themes with sub-themes emerged. Theme #1: Minnesota’s current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.ConclusionAligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs’ perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.Electronic supplementary materialThe online version of this article (10.1186/s12939-018-0872-3) contains supplementary material, which is available to authorized users.

Health Care Professionals’ Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

“…Table 1 provides details related to the time period of program implementation since the inception of P4P in the early 2000s (early, evolving, and routinization), as well as the program design as described by the authors of each article. Nine articles were focused on studies based in the United Kingdom, 34,35,39,40,42,43,[45][46][47] 7 articles in the United States, 33,37,38,48,49,51,52 1 article each in Tanzania, 36 Malawi, 44 France, 50 and the Netherlands. 41 Twelve articles focused on physicians, nurses, and health care professionals, 5 articles focused on physicians, one of which also included practice executives, 2 articles focused on practice executives/leaders, and 1 article focused on nonphysician health care professionals.…”

“…." 37 Another study participant reflected that quality target feedback is important to show the clinical care performance. A GP remarked, "I thought I was doing well, but now I get more insight into what happens."…”

“…55 Study participants noted that physicians and nurses were motivated to provide good quality care and that the P4P programs legitimized their intrinsic motivation to improve outcomes for their patients. 33,34,36,37,40,44,[50][51][52] "Personally, the incentives are just an addition, but my spirit is to help people. Nursing is a calling.…”

“…42 Another respondent noted, "the boxes were checked." 37 Nurses were often delegated the role of checking the box. Within this domain, respondents lamented the increased role of health information technology and the intrusion on clinical practice and the provider-patient relationship.…”

Atuação cotidiana no Sistema Único de Saúde em sua terceira década

“…9,10 Studies conducted in the United States have shown that continuity of care improves equity, and it favors the quality of health, enabling the interaction of professionals with users, in addition to improvement in care. 11,12 Difficulties encountered by professionals to work at SUS are an impacting factor in the daily life of health services, since they compromise the implementation of SUS principles and guidelines, making it impossible to provide comprehensive care to the population. 6,13 Therefore, the proposal of this study is justified by the relevance of understanding the daily life of SUS, in its third decade, from the perspective of PHC health professionals in three cities of Minas Gerais and questioned: how is the daily practice in the SUS, in three cities of the state of Minas Gerais, Brazil, from the perspective of PHC health professionals?…”