Checklist developed to help determine viability of quality pay programs

After numerous mixed reviews of pay-for-performance incentive plans, researchers from Australia have developed a nine-point checklist to determine if a program will have the desired outcomes. Although the list was developed for program organizers, they say physicians can benefit from it by finding out whether they should participate in an incentive program.

Many efforts have been launched in recent years, by both Medicare and private plans, to improve quality and outcomes by paying physicians incentives for their performances. Some show positive outcomes, and others reveal either little evidence of improvements or unintended consequences, according to a report published Aug. 14 by Australian researchers in the British Medical Journal.

The report details a checklist that not only will help pay-for-performance program organizers determine whether a program is warranted, but also can help them design the program more effectively, researchers said (link).

Although the list was aimed at those planning an incentive, study co-author Paul Glasziou, a professor in the Center for Research in Evidence-based Practice at Bond University in the Gold Coast of Queensland, Australia, said he has had a lot of interest from physicians who want to use the list to determine whether to participate in a program.

Performance-based incentives are becoming an increasingly larger portion of a physician’s overall salary. The Hay Group found in its 2011 physician compensation survey that 64% of the health care organizations surveyed used an annual incentive plan in 2011 for employed physicians. Only 49% did so in 2008.

The first six items on the list can help determine if an incentive program should be considered at all. The authors said questions 1-3, in particular, should be answered positively on first pass. When all of the first six questions in Part A are answered with a “yes,” the three questions in Part B will help them with the program’s design.

The first three questions:

Does the desired clinical action improve patient outcomes? Researchers say there should be strong evidence that the desired change in physician behavior will produce improved patient outcomes. They advocated evidence such as high-quality randomized trials, as opposed to guideline recommendations alone. As an example, they used a program offering incentives to achieve a glycated hemoglobin target of less than 7% in diabetic patients that was based on prognostic data from cohort studies, despite the fact that three large trials showed no evidence of the benefits of that target compared with higher ones.

Will undesirable behavior persist without intervention? Glasziou said one program examined in the study did not work, in part, because the problem — elevated hemoglobin A1c levels — already was correcting itself.

Are there valid, reliable and practical measures of the desired clinical behavior? The study authors said the measure should be practical, and the cost of collecting the data to show the outcome must be outweighed by the benefits to patients.

The remaining three questions in Part A look at: the barriers to improving clinical behavior; whether financial incentives are the best way to achieve changed behaviors; and the unintended consequences of a program.