August, 2008 - SUPPORT Summary of a systematic review | print this article |
Explicit financial incentives have been proposed as a strategy to change physician and healthcare system behaviour. Linking payments at different levels in the health system to performance on quality measures is currently being used by a number of organisations in the USA and other high-income countries. The incentives have been implemented at different levels, including the payment system; the provider group; and the individual physician.
− Decrease hospital admission rates or death of nursing home patients;
− Produce adverse selection of users;
− Improve access to community mental health care;
− Improve some processes of care such as influenza immunisation rates and diabetes care.
− Resources to finance the incentives beyond restructuring existing payment systems;
− Routine data on quality of care.
The review included 17 studies evaluating explicit financial incentives on quality of care measures. Four of them were conducted in North America while the other 13 studies appear to have been carried out in high-income settings (mostly the USA).
There was no explicit definition of “payment-system level”, but it seems to be a nonprovider organisation commissioning specific services on behalf of its clients from a provider organisation. The two studies identified employed different designs (1 randomised trial and 1 controlled before-after study), and focused on very different populations (nursing home patients versus Medicaid Office of Substance Abuse clients) in the US health system.
Nine studies (5 randomised trials, 2 controlled before-after studies and 2 crosssectional surveys) were identified, mostly from the USA. Eight of these evaluated the effects of financial incentives on process measures of quality, mainly related to preventive care. The other study aimed to improve access to services offered by community mental health centers.
Six studies (3 randomised trials, 1 controlled before-after study and 2 cross-sectional surveys) evaluated financial incentives at the individual physician level. In the four experimental studies the incentive was a bonus or an enhanced fee-for-service payment given at different intervals. The magnitude of the incentive was variable and depended on the type of behaviour targeted (range: US $50 to US $7500).
This report provides an overview of the evidence for both supply and demand side results-based financing (pay for performance) in the health sector with the primary focus on low and middle-income countries: Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Report Nr 16-2008. Oslo: Nasjonalt kunnskapssenter for helsetjenesten, 2008.http://www.kunnskapssenteret.no/Publikasjoner/3219.cms?threepage=1
This paper provides a discussion of both supply and demand side pay for performance and case studies from low and middle-income countries:Eichler R. Can ”Pay for Performance” Increase Utilization by the Poor and Improve the Quality of Health Services? Discussion paper for the first meeting of the Working Group on Performance-Based Incentives. Washington DC: Center for Global Development, 2006; 5. http://www.cgdev.org/doc/ghprn/PBI%20Background%20Paper.pdf
A general analysis about payment for performance in health care with useful reference is presented in:Mannion R, Davies HTO. Payment for performance in health care. BMJ 2008;336:306-308.
This study reports findings of a cross-sectional survey for the first-year of the national pay-forperformance program in family practices in the UK: Doran T, Fullwood C, Gravelle H, Reeves D, Konropantelis E, Hiroeh U, Roland M. Pay-for-Performance Programs in Family Practices in the United Kingdom. N Engl J Med 2006;355:375-84.
Tomás Pantoja, Escuela de Medicina, Pontificia Universidad Católica de Chile.
None declared. For details, see: http://www.support-collaboration.org/summaries/coi.htm
This summary has been peer reviewed by: Laura Petersen, USA; Paul Smithson, Tanzania; Atle Fretheim, Norway; Tracey Perez Koehlmoos, Bangladesh; Maylene Beltran, Philippines.
Pantoja T. Does pay-for-performance improve the quality of health care? A SUPPORT Summary of a systematic review. August 2008. http://www.support-collaboration.org/summaries.htm