“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”
In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.
He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.
In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.
Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.
But, for five measures—chlamydia testing, hemoglobin A1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement.
And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.
Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.
There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”
Money indeed may turn out to be the pressing issue as pay for performance becomes more common.
Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.
But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.
“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.
“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.
Fragmented Care Poses Challenges
Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.
The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.
Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.
Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.
Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.
During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.
According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.
These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.
The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.