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Filling the gaps between performance incentive programs and health care quality improvement.

Article Excerpt
Restructuring payment policies through performance incentive programs to explicitly promote improvements in the quality and value of health care has become a popular strategy for public and private health care payers. But our measures of quality are less than comprehensive, and current performance incentive strategies to improve quality may exacerbate disparities in health care.

Despite the proliferation of pay-for-performance (P4P) and other performance incentive programs, data on whether they work to improve quality are scant and, where data exist, the results have been mixed. Over 40 P4P programs are known to focus on inpatient care alone, yet only eight peer-reviewed articles have assessed the effects of these programs on clinical quality, patient experience, safety, or resource use (Mehrotra et al. 2009). These studies have found some improvements in quality, but they also noted methodological problems in the assessments, which did not preclude the possibility that the improvements were due to temporal trends alone. Some of the largest assessments have found no significant improvements in quality (Lindenauer et al. 2007). Most remarkable, however, is that not a single one of these studies has reported data on the impact of these emerging P4P programs on equity (closing racial, ethnic, linguistic, and other socioeconomic gaps in health status), which is one of the six key dimensions of quality identified by the Institute of Medicine (Institute of Medicine Committee on Quality of Health Care in America 2001).

This lack of investigation is especially striking because the potential for P4P programs to create unintended adverse consequences on equity is a well-recognized concern. Indeed, the lack of evidence regarding likely hazards of performance incentive programs for vulnerable populations and providers that care for them, such as safety net hospitals, has been a focus of particular concern and discussion for some time (Chien et al. 2007). Commentators have outlined several potential mechanisms through which P4P could worsen health disparities--including the creation of incentives for providers to avoid patients perceived to be more likely to have low-quality scores (cherry picking), the promotion of one-size-fits-all quality improvement initiatives that may be less effective for racial or ethnic minority groups or for patients with limited health literacy, and the widening of the resource gap for providers who care for these populations. Yet empirical research in this area is lagging.

The lack...

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