Performance related pay doesn’t improve quality of primary care, US study finds

Performance related pay for doctors in primary care does not result in better quality of care for patients, a large Massachusetts study has concluded. Reward schemes in commercial health plans in the United States may be too low to make a difference to physicians’ performance, the researchers said.

The study, which involved about 5000 primary care doctors and nearly four million patients, found that the performance of most doctors improved on all measures of clinical quality whether or not they had incentives (Health Affairs 2008;27:1167-76).

Performance related pay (called “pay for performance” (P4P) in the US) has been widely introduced as a way to improve patients’ care, but, the authors say, few studies have evaluated its effectiveness. They note that Medicare, the federal health insurance programme for elderly people, has implemented performance related pay in hospitals and may introduce payments to individual doctors.

“We found no relationship between the magnitude of quality improvement and specific P4P contracts,” the authors say.

A key question is how much money is needed to motivate improvements in clinical quality, the authors say.

The incentives, provided to doctors by commercial healthcare plans, ranged from about $200 (£100; €130) to $2500 per primary care doctor in the Massachusetts contracts. At the group level, payments for compliance with performance standards ranged from $10 000 for a small practice complying with two of 13 performance standards to $2.7m for one of the largest groups complying with five performance standards.

The authors note the contrast between the typical amounts paid per doctor in the US and the bonuses that GPs can earn in the United Kingdom, where the amounts paid under the quality and outcomes framework (QOF) can be a substantial proportion of GPs’ income. Bonuses under the QOF system can reach £120 000 for an average sized practice of three GPs. The authors say that recent national US data indicate that only about 40% of pay for performance contracts may include a maximum bonus greater than 5% of physicians’ income.

The Massachusetts study looked at the effect on quality of care of the various performance related pay schemes that five large commercial health plans introduced into contracts with groups of primary care physicians in 2001-3. The authors used a quality measurement and reporting system set up by the state to ascertain whether the programmes improved quality and whether some were better than others.

The study compared changes in 13 performance standards set by the National Committee for Quality Assurance from 2001 to 2003 among patients in 81 practices where the doctors were eligible for incentives and in 73 groups that were not eligible.

The standards covered prescribing of antidepressants and asthma treatments, screening for chlamydia and high cholesterol, comprehensive diabetes care, and child and adolescent care.

More than 90% of primary care doctors in Massachusetts participated in the programmes. They included internists, family doctors, paediatricians, and specialists who served as primary care doctors for some patients. The study excluded physicians from groups with fewer than three primary care providers. The final sample included 5350 physicians from 154 groups.