The Relationship between Pay-forPerformance Incentives and Quality
Improvement: A Survey of Massachusetts
Physician Group Leaders
Ateev Mehrotra, Steven Pearson, Kathryn Coltin, Ken
Kleinman, Janice Singer, Barbra Rabson, Eric Schneider
RAND Pittsburgh, University of Pittsburgh, Brigham and Women’s Hospital, Harvard
Medical School, Harvard School of Public Health, and Massachusetts Health Quality
Partners
Supported by the Robert Wood Johnson Foundation Rewarding Results Initiative and an National
Research Service Award (#6 T32 HP11001-17)
1
Previous Research
Few published studies on P4P incentives
have shown limited or no impact 1
 Potential reasons

 Providers
reject concept
 Magnitude not significant
 Insufficient time
1. Rosenthal and Frank. Med Care Research
Review, Rosenthal et al. JAMA. 2005 Oct 12,
294:1788-93.
2
Research Questions
1.
2.
3.
4.
What is the prevalence and magnitude of
P4P incentives?
Are these incentives financially important
to physician groups?
Do P4P incentives lead to increased use of
QI initiatives?
How do physician group leaders view P4P?
3
Study Sample
100 groups on Massachusetts 2005 physician
group report card
 Interviewed leaders of 79 groups between
May and September 2005
 Semi-structured phone interviews lasting 3060 min

4
Physician Group Characteristics
(n=79)
Number of Primary Care Providers
%
<= 10 MD
11-25 MD
26-100 MD
> 100 MD
Significant Capitation
(>25% of commercial revenue)
13
28
41
18
13
5
Research Questions
1.
2.
3.
4.
What is the prevalence and magnitude of
P4P incentives?
Are these incentives financially important
to physician groups?
Do P4P incentives lead to increased use of
QI initiatives?
How do physician group leaders view P4P?
6
Prevalence and Magnitude of
P4P in Massachusetts
Groups with P4P
incentives in health plan
contracts
Overall revenue tied to
P4P
89%
2.2%
(0.3 – 8.0)*
* Limited to 37 groups
7
Focus of Current P4P Incentives
Among Groups with Any P4P (n=71)
Measures
Groups reporting any
P4P tied to measure
%
HEDIS measures
100
Utilization measures
64
Use of EMR or other IT
51
Patient Satisfaction Survey Measures
35
8
Research Questions
1.
2.
3.
4.
What is the prevalence and magnitude of
P4P incentives?
Are these incentives financially important
to physician groups?
Do P4P incentives lead to increased use of
QI initiatives?
How do physician group leaders view P4P?
9
Evaluation of Financial Importance
Stratified by Revenue at Risk
% of Overall
Revenue tied to
P4P
N*
<1%
19
P4P are “very important” or
“moderately important” to
group’s financial success
%
11
1-3%
9
22
>3%
9
56
* Limited to 37 non-IPA groups with P4P
Mantel-Haenzel chi-squared test for trend significant with p value of 0.01
10
Research Questions
1.
2.
3.
4.
What is the prevalence and magnitude of
P4P incentives?
Are these incentives financially important
to physician groups?
Do P4P incentives lead to increased use of
QI initiatives?
How do physician group leaders view P4P?
11
Use of QI Initiatives
HbA1c Measurement
Mammogram Screening
Asthma Controller Medication Use
Adequacy of Well Child Visits
Chlamydia Screening
Hyperlipidemia Screening
LDL control
Hypertension Control
0
20
40
60
80
100
12
Relationship between P4P & QI
Initiatives
HbA1c Measurement
Mammogram Screening
Asthma Controller Medication Use
Adequacy of Well Child Visits
Chlamydia Screening
Hyperlipidemia Screening
P4P Incentive
LDL control
QI Initiative
Hypertension Control
0
20
40
60
80
100
13
Variables Associated with Increased
Use of QI Initiatives
Pay-for-performance incentive
Employed Physician Group
Larger group (>39 physicians)
Odds Ratio
(95% CI)
P
Value
1.6
(1.0-2.4)
3.2
(1.5 – 7.1)
2.2
(1.0 - 4.9)
0.04
0.004
0.06
14
Research Questions
1.
2.
3.
4.
What is the prevalence and magnitude of
P4P incentives?
Are these incentives financially important
to physician groups?
Do P4P incentives lead to increase use of
QI initiatives?
How do physician group leaders view P4P?
15
Views of P4P
% of Physician
Group Leaders
Physician groups should be
paid based performance on
HEDIS measures
P4P will lead to quality
improvements over next 3
years
77
79
16
Limitations
Findings do not address any problems with
how current P4P incentives are structured
 Does not address actual performance on
quality measures
 Cannot comment on potential adverse
impacts of P4P incentives

17
Key Findings




Vast majority of groups face P4P
Leaders support concept of P4P tied to HEDIS
measures
Current magnitude of P4P may be insufficient
P4P incentives are associated with increased use
of QI initiatives
18
Policy Implications



Support among physician leaders for incentives
based on quality
Help us understand the necessary financial
magnitude of incentives
Demonstrate potential for pay-for-performance
incentives to increase attention paid to quality
improvement
19
For further information:
mehrotra@rand.org
20
Independent Variables in Model







P4P Incentive on that measure
Percentage of Employed Physicians (majority vs. less
than majority)
Use of EMR (majority use EMR vs. less than majority)
Size of group (>39 PCP vs. <=39 PCP)
Types of MD (Mostly specialty vs. Equal mix or mostly
primary care)
Significant capitation
Part of a Network
21
Assessing Prevalence of QI
Initiatives
 Focus on 8 HEDIS measures
 Open-ended question
 Follow-up questions to determine
whether met criteria for 12 prespecified categories of QI initiatives
 Not all reported QI initiatives coded
22
Measures Discussed in Interview


HEDIS measures
Patient satisfaction
survey results
 Utilization measures
 Use of EMR or other
IT








Asthma Controller
Medication Use
Adequacy of Well Child
Visits
Chlamydia Screening
Mammogram Screening
HbA1c Screening
Hyperlipidemia Screening
in patients with CAD
LDL control among
patients with CAD
Hypertension Control
23
Ideally What % of Overall Revenue
Should be Tied to P4P Incentives?
% of Physician
Group Leaders
Ideal Percentage 5% or
Greater
91
24