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Effect of Physician Pay-for-Performance (P4P) Incentives in a Large Primary Care Group Practice

Effect of Physician Pay-for-Performance (P4P) Incentives in a Large Primary Care Group Practice. Presenter: Harold Luft, PhD 1,2 Collaborators: Sukyung Chung, PhD 1,2 , Latha Palaniappan, MD, MS 1 Haya Rubin, MD, PhD Laurel Trujillo, MD 3 Eric Wong, MS 1

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Effect of Physician Pay-for-Performance (P4P) Incentives in a Large Primary Care Group Practice

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  1. Effect of Physician Pay-for-Performance (P4P) Incentives in a Large Primary Care Group Practice Presenter: Harold Luft, PhD1,2 Collaborators: Sukyung Chung, PhD1,2, Latha Palaniappan, MD, MS1 Haya Rubin, MD, PhDLaurel Trujillo, MD3Eric Wong, MS1 1Palo Alto Medical Foundation Research Institute 2Institute for Health Policy Studies, UCSF 3Palo Alto Medical Foundation Supported by AHRQ Task Order HHSA290200600023

  2. Empirical Evidence of P4P • Recent studies of P4P show modest effects • Group level incentives • Rosenthal et al. (2005): increase in cervical cancer screening, but no effect on mammography and HbA1c testing • Roski et al. (2003): better documentation of tobacco use, but no change in provision of quitting advice • Physician-specific (vs. no) financial incentives) • Levin-Scherz et al. (2006): increased diabetes screening, but no effect on asthma controller prescription • Beaulieu & Horrigan (2005): improvement in most of the process and outcome measures of diabetes care • Gilmore et al. (2007): improvement in most process of care measures (e.g. cancer screening, diabetes care) • Financial incentives were generally accompanied by other quality improvement efforts such as performance reporting

  3. Empirical Evidence of P4P (cont.) • Limitations of previous studies: • Payer-driven initiatives • Quality measures and incentive schemes were given to, rather than chosen by, physicians or physician groups. • Only part of the physicians’ patients were eligible for incentives. • Incentives paid annually or at the end of the study • Effect of timing of receipt of payment, in addition to the provision of performance reporting, is unknown. • Based on claims data • Limited physician-level information; no opportunity to investigate specific physician characteristics associated with incentives

  4. Research Questions • Does a P4P program with physician-specific incentives implemented in a large primary care group practice improve quality of care provided? • Are there associations across measures (within physicians) in the effect of the incentive program? • What physician characteristics affect variations in performance across physicians? • Does the frequency of payment (quarterly vs. end-of-year) make a difference in performance?

  5. Study Setting • Palo Alto Medical Foundation (PAMF) • Non-profit organization • Contracts with 3 physician groups in Northern California • Palo Alto Division (PAMF/PAD) • 5 sites: Palo Alto, Los Altos, Fremont, Redwood City, Redwood Shores • Physician payment: based on relative value units of service • Electronic health records since 2000 • Implemented physician-specific financial incentives in 2007

  6. The Incentive Program • Physician-specific incentives based on own performance • Comprehensive • All the primary care physicians (N = 179) and all their patients regardless of insurance type • Family Medicine, Internal Medicine, Pediatrics • Physician participation • in determining performance measures and incentive formula • Frequency and amount of bonus payment • Physicians were randomly assigned to quarterly or year-end payment • Maximum bonus: $1250/qtr or $5000/yr (~2-3% of salary) • Payment delivered about 6 weeks following the evaluation quarter

  7. The Incentive Program (cont.) • Various quality measures • Both outcome and process measures • 10 were selected from a set of existing measures used for quality assessment for several years • 5 new pediatrics-specific measures were selected based on AAP guidelines; some were further modified during the year • These pediatric measures are excluded in our analyses • Quarterly performance reporting • All the physicians were alerted by quarterly email with an electronic link to quality workbook (a process in place for several years) • In 2007, the report was to be sent on the 24th day after the quarter • Funds • IHA P4P incentives were supplemented by the organizational fund • Allowed application to all patients, not just those in IHA plans

  8. Incentivized Quality Measures Percent score = [numerator (i.e. patients who met the guideline) / denominator (i.e. patients who were eligible for the recommended care)] X100 * Similar measures (with different targets and population) were included in the IHA P4P program. †These measures apply to some pediatrics patients.

  9. Other Quality Measures: Examples* These were not incentivized, but were reported in the quality workbook.

  10. 6mGly7 Score-FAMP 100% 90% 80% 70% 60% % 50% score 40% 30% 20% 10% 0% P1 P4 P7 P10 P13 P16 P19 P22 P25 P28 P31 P34 P37 P40 P43 P46 P49 P52 P55 P58 P61 P64 P67 Provider Example: Quality Workbook for “Diabetes HbA1c Control” Stretch goal (point=3) Intermediate goal (point=2) Minimum goal (point=1)

  11. Incentive Formula • Incentive payment = composite score * maximum amount {=$1250/quarter} • Composite score = (∑ achieved points) / (3 * #qualifying measures) {Measures with <6 eligible patients for a physician in a quarter were not counted as a qualifying measure} • Physicians with <4 qualifying measures in a quarter were not paid for the quarter

  12. Number of Participating Physicians *Among the initial sample (n=179), 12 physicians did not participate in the program due to various reasons (e.g. lack of number of patients, medical/sabbatical leave, etc.).

  13. Quality Scores, Number of Patients and Physicians at Quarter I, 2007

  14. Analyses • Does the 2006-07 change differ from 2005-06? • H: (p2007 – p2006) – (p2006 – p2005) =0 • Outcome variables: Percent scores for incentivized and not-incentivized measures • Unit of analysis: physician, each measure, each year (2005-2007) • Does the trend in Palo Alto Division differ from the trend in other PAMF divisions? • H: PAD [(p2007– p2006)–(p2006–p2005)] – Other [(p2007– p2006)–(p2006–p2005)] =0 • Outcome variables: Percent scores for quality measures similar to the incentivized ones, but that were applied only to HMO patients • Unit of analysis: medical group, each measure, each year (2005-2007) • Does the frequency of payment make a difference in quality? • H: p(Quarterly-paid, 2007) – p(Annually-paid, 2007) =0 • Outcome variables: Percent scores for incentivized measures • Unit of analysis: physician, each measure, four quarters of 2007

  15. Q1 Q2 Q3 Q4 Quality Scores: Four Quarters, 2007 *p<0.05; ** p<0.01 Ref.cat.: Q1 * * * ** * ** ** ** ** ** * Diabetes Diabetes Diabetes Asthma Cerv.cancer Chlamydia Colon cancer Ht Wt HbA1c ctrl BP ctrl LDL ctrl Rx screening screening screening measured

  16. Percent Scores: 2005-2007(incentivized measures) *p<0.05; **:p<0.01 †Statistics based on the results from the multilevel mixed-effects linear regression (z-statistics). ‡Parentheses are used when the difference ((p2007 – p2006) or (p2006 – p2005)) is negative.

  17. Percent Scores: 2005-2007 (reporting only measures) *p<0.05; **:p<0.01 †Statistics based on the results from the multilevel mixed-effects linear regression (z-statistics). ‡Parentheses are used when the difference ((p2007 – p2006) or (p2006 – p2005)) is negative.

  18. Effects of the Physician Incentive Program† † Difference-in-differences in pscore (p2007 – p2006) – (p2006 – p2005) ‡ 90th percentile coefficient could not be estimated because there is no variation in the scores.

  19. Effects of Physician Characteristics * p<0.05; ** p<0.01 Linear regression; other covariates included are indicators of each quality measure and practice site.

  20. Controlling Blood Sugar for Diabetes Patients Asthma Rx 1.00 1.00 0.90 0.90 0.80 0.80 PA PA CMG CMG SCZ SCZ 0.70 0.70 0.60 0.60 0.50 0.50 2005 2006 2007 2005 2006 2007 measurement year measurement year Comparison to Other Groups’ Scores (2005-2007)* These are IHA P4P measure scores. Definitions of the measures were similar to those incentivized at PAD, but the eligible patients for the IHA measures are limited to HMO patients.

  21. Cervical Cancer Screening Chlamydia Screening 1.00 1.00 0.90 0.80 0.60 0.80 PA PA CMG CMG SCZ SCZ 0.40 0.70 0.20 0.60 0.00 0.50 2005 2006 2007 2005 2006 2007 measurement year measurement year Comparison to Other Groups’ Scores (2005-2007) (Cont.) These are IHA P4P measure scores. Definitions of the measures were similar to those incentivized at PAD, but the eligible patients for the IHA measures are limited to HMO patients.

  22. Correlation in Scores Across Measures (within physicians) Y: Hx tobacco entered (P4P) X: Hx alcohol entered (non-P4P) Y: Diabetes BP control (P4P) X: Diabetes HbA1c control (P4P) Y: Colon cancer screening (P4P) X: Diabetes HbA1c control (P4P)

  23. Does the Frequency of Payment Matter? * p<0.05; ** p<0.01 Estimation methods: random effect linear regression Other covariates included are indicators of each quarter, quality measure, practice site and department.

  24. Bonus Amount by Study Arm *No statistical difference between two study arms. †For the first quarter, there was two months delay in the reporting and payment.

  25. Summary of Findings • Physician incentives have a modest effect on the improvement of some measures • Improvement in quality scores over the past three years for the incentivized and other related measures. • For three measures (BP control of diabetes patients, colon cancer screening, tobacco Hx documentation), the improvement accelerated with the incentive program. • Similar trend is observed in a measure (BP control of hypertension patients) that was not incentivized, but was reported to the physicians. • The trend is not distinctively different from trends of two groups which did not have the same incentive program, but also underwent various quality improvement efforts. • Other organizational or regional quality improvement effort may have confounded the effect of P4P.

  26. Summary of Findings • Within- and across- physician variations • For each measure, within physician scores are consistent over time • No strong correlation across measures within a physician • More improvement among physicians whose score was middle or lowest in the previous year than those with highest score (data not shown) • Frequency of incentive payment (quarterly vs. end- of-year) does not make a difference • No difference in scores or changes in scores over time between the two groups based on frequency of payment. • Similar improvement in both arms for most measures. • The effect of quarterly (vs. end-of-year) incentive payment may have been mitigated by the quarterly report sent to both arms.

  27. Conclusions • Physician-specific incentives appear associated with modest acceleration in improvement in some targeted measures. • The frequency of payment by itself does not make a difference in performance in response to the P4P program. • In the context of other organizational-level quality improvement efforts, relatively small financial incentives to individual physicians have limited incremental effects on well-established measures. • Other incentives (e.g. increasing coverage of staff hours for quality improvement) should be explored.

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