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Field Investigation of the Role
of Provider Attitudes in the
Impact of Pay-forPerformance Programs
Gary Young
Professor and Chair
Department of Health Policy and Management
Boston University School of Public Health
Presentation for AcademyHealth
2009 Annual Meeting
Financial support from a Robert Wood Johnson Foundation
Investigators Award in Health Policy
Pay-for-Performance and the US
Health Care Industry


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Over 150 programs in the private sector.
Medicare Value-Based Purchasing
initiative.
Over 28 state Medicaid agencies have
adopted pay-for-performance programs.
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Theoretical Perspectives
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Financial Incentives –- e.g., Agency
Theory, Expectancy Theory.
Performance Goals –- Goal Setting Theory
Intrinsic Motivation –- (e.g., Human
Relations School)
Professional Autonomy – Occupational
Sociology
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Research Questions
 In
the context of a pay-forperformance (P4P) program, do
financial incentives lead to better
quality of care?
 What
contextual factors may be
important in moderating the effect of
financial incentives on provider
behavior?
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Competing Perspectives

Instrumental Perspective:
– Assumes largely direct relationship between
financial incentives and performance.
– Key constructs pertain to the perceived
salience of the incentive and achievability of
performance target.

Crowding-Out Perspective:
– Assumes that people often approach work
with high degree of intrinsic motivation.
– Key constructs pertain to intrinsic
motivation, locus of control, perceptions of
work autonomy.
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Hypotheses
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In the context of a pay-for-performance program,
financial incentives will be positively associated
with improved physician performance on selected
quality measures.
In the context of a pay-for-performance program,
physician perceptions of the program’s impact on
their professional autonomy will moderate the
effect of financial incentives on physician
performance. The more physicians believe the
program undermines their autonomy, the less
responsive they will be to the financial incentives.
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Methods
 Methodological
challenge – field
versus laboratory investigation for
assessing the role of attitudes.
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Methods
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Study Setting: Physician network (IPA) in Rochester NY.
– Implemented tournament-style P4P program for
diabetes care
– > 300 PCPs
– Quality measure: Percentage of expected number of
diabetic exams/screens (LDL, 2 HbA1c, urinanalysis, eye
exam) conducted.
– Financial incentive: 50 to 150% of withhold payment
– Potential payout up to about $3,000 for diabetic
component
Study Design
– Quasi experiment with longitudinal data
– Baseline assessment of attitudes toward incentive
program
– Quantitative and Qualitative data collection
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Methods
Data:
– Administrative
– Survey of physicians at baseline
 Approximately
335 physicians surveyed
 Approximately 48% response rate
 No performance differences between
respondents and non-respondents
– Interviews/ Focus Groups with
managers and front-line staff
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Methods
Scale Development for Autonomy
Measure
– Conceptual development
– Psychometric testing
– Pilot testing/Cognitive debriefing
– Example items:
 The
incentive program interferes with how I
care for my patients.
 The physician network encourages my
questions and feedback about the quality
targets.
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Methods
 Analysis
– Analysis of Covariance
 Financial
incentive and time treated as
factors
 Covariates (assessed at baseline): attitudes
(autonomy, self efficacy, and goal
commitment); demographic characteristics
(specialty, practice size, and experience)
 Main effect tested for incentive
 Interaction tested for incentive and
autonomy
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Results
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Small main effect for financial incentive
alone.
Statistically significant interaction of
financial incentive and autonomy.
Qualitative data revealed as a major
theme that incentives had greater
symbolic than instrumental value.
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Overview: Six-Year Trends in RIPA Diabetes Care
(n=334)
HbA1c Check
Urinalysis
LDL Check
Retinal Exam
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Mean Adherence Rate (patients per physician)
0.8
0.7
0.6
0.5
0.4
0.3
0.2
Pre-Incentive
Post-Incentive
2001
2002
0.1
0
1999
2000
2003
2004
Figure 1
Physician Performance Score for Diabetes P4P,
1999-2004
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0.7
Measure
0.65
0.6
0.55
0.5
0.45
0.4
1998
1999
2000
2001
2002
Year
2003
2004
2005
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Six Year Trends in RIPA Diabetes Scores
Stratified by Physician Perceptions of
Autonomy
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Conclusions
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The autonomy scale demonstrated good
psychometric properties and discriminated
among physicians.
The field investigation proved to be effective
for examining a potentially important
moderator of the relationship between
financial incentives and performance.
The results raise an interesting theoretical
question: Why do physicians in the same P4P
program differ in their perceptions regarding
the degree to which the incentive system
undermines their professional autonomy.