Pay-for-performance programs may be ineffective in motivating physician quality improvement because they're too generic and stingy.
A new study published in the American Journal of Managed Care looked at P4P programs in 79 physician groups in Massachusetts, one of the few states in which most health plans have implemented physician quality incentive efforts.
"In terms of the relationship between pay-for-performance and the quality improvement, we found that those physician groups that had a pay-for-performance program targeting a specific measure were statistically more likely to have quality improvements targeting that measure," said the study's lead author, Ateev Mehrotra, MD, assistant professor at the University of Pittsburgh School of Medicine and policy analyst for RAND Corp.
Previous pay-for-performance efforts have yielded mostly negative results, Mehrotra noted, but it's not clear why physicians aren't motivated to improve performance.
"Is the money not enough? Do the physicians not agree with the incentives? Are they even initiating the efforts? Our study looked into those concerns," Mehrotra said. The study found that most physicians are initiating improvement efforts, support pay-for-performance initiatives and generally agree that the financial incentives are not large enough.
"On one hand, if we give money tied to a specific measure, (physicians) should respond positively, but they also say it's not enough," Mehrotra said. "One of the problems is we can't give an answer on the right amount of money."
Among physicians interviewed in the study, 91 percent said the ideal percentage of total revenue tied to pay-for-performance incentives should exceed 5 percent.
Greg Meyer, MD, medical director for the physician organization of Massachusetts General Hospital and senior vice president for quality and safety at MGH, said the study on pay for performance looked at three categories of measures, – those related to utilization, quality and infrastructure.
Meyer said utilization measures are the most difficult in physician engagement because it is not always clear exactly what steps should be taken. "(Physicians) are much less excited about utilization issues than things they think are directly related to quality," Meyer said. As a result, classic evidence-based quality issues are more successful in terms of motivation within pay-for-performance initiatives, he said.
Improvement measures that involve infrastructure and workflow changes, such as implementing an electronic medical record, can be the most challenging in terms of motivating physicians.
"Most providers literally spend a month or two of evenings not seeing their families in order to get onto the electronic medical record," Meyer said. "There is no incentive you can pay me that would make up for the nights that I didn't see my wife and children."
Mehrotra noted that monetary incentives are only one of a number of factors providers consider when participating in pay-for-performance initiatives.
"You can't use pay-for-performance to drive every change you want through medicine," Meyer said. The improvement measure “has to be credible and important, but if it is, it can help move the ball a little bit."