Checklist developed to help determine viability of quality pay programs

Studies have found mixed results with incentive-based initiatives, so experts have developed a way to see which stand the best chance of succeeding.

By — Posted Sept. 6, 2012

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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.

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9 questions to assess pay-for-performance programs

Researchers developed a nine-point checklist to determine when a pay-for-performance program may be beneficial. The first six questions help figure out whether the program is warranted. Ideally, all questions should be answered affirmatively. The last three questions, which are open-ended, can help with the design of the program.

Does the desired clinical action improve patient outcomes? Guideline recommendations alone usually are insufficient. High-quality randomized trials showing that the desired clinical action will result in improved patient outcomes are best.

Will undesirable clinical behavior persist without an intervention? Many problems resolve on their own without intervention.

Are there valid, reliable and practical measures of the desired clinical behavior? Measures for incentives must be valid and not too costly as to outweigh the benefits.

Have the barriers and enablers to improving clinical behavior been assessed? Barriers need to be understood to determine how quickly and how sustainable a proposed change will be.

Will financial incentives work, and will they work better than other interventions to change behavior? Many other interventions, besides financial incentives, can be used to change clinical behavior, such as education, audit and feedback, opinion leaders, reminders, collaborative quality improvement, regulatory approaches and public reporting.

Will benefits clearly outweigh any unintended harmful effects and at an acceptable cost? Unintended consequences of change include: attention shifts that result in a decrease in quality elsewhere; gaming behavior aimed at earning the incentive without necessarily improving outcomes; harm to the patient-physician relationship; and inequalities in the achievement of targets by age, sex and ethnic groups that persist after the program.

Are necessary systems and structures for the change in place? Investments in infrastructure may be needed before the incentive plan is launched.

How much should be paid to whom and for how long? Researchers say the largest improvements come from payments to individuals and teams rather than organizations. But the targets can’t be set too high or low to prevent some from being discouraged from not earning, or from some earning too much and diminishing the funds.

How will the financial incentives be delivered? The rules must be explicit while retaining flexibility.

Source: “When financial incentives do more good than harm: a checklist,” British Medical Journal, Aug. 14 (link)

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