Quality or Productivity First? Now We Know

April 10, 2013
Much has already been written about in what ways, and to what degree, pay-for-performance programs may or may not influence physician behavior.

Much has already been written about in what ways, and to what degree, pay-for-performance programs may or may not influence physician behavior. But now comes along a new study from UCLA that has finally dotted the “i’s” and crossed the “t’s” on a key question: should such programs consciously incent quality, or productivity, or both?

Hector P. Rodriguez, an assistant professor in the department of health services at the UCLA School of Public Health and his colleagues found that physicians incented towards improved communication with patients, care coordination, and office-staff interactions, substantially improved their behaviors in the context of the Integrated Healthcare Association’s P4P program. Incentives for addressing the quality of patient-clinician interaction and the overall experience of patient care tended to result in improved performance in those areas, particularly when the incentive funds were used broadly by the physician groups to positively reinforce a patient-centered work culture.

But within those medical groups in which individual physicians were incented towards increased productivity (the IHA allows physician groups considerable leeway in how they internally manage their participation its program), patients actually ended up having a diminished patient experience. The study was a broadly based one, involving 1,444 primary care physicians at 25 California medical groups between 2003 and 2006.

“As the Obama administration and Congress continue to grapple with healthcare reform, these findings provide timely information about the kinds of things medical groups can do—and can avoid doing—with financial incentives in order to improve the quality of patient healthcare experiences,” Rodriguez said in a UCLA press release.

And though it’s important to avoid over-generalizing any kind of study of this type, it would be hard not to see some obvious lessons from this study for clinician incentivization across any patient care setting. As I noted in my September cover story on CPOE, those hospitals and health systems in which CPOE implementation has been most successful have been ones in which clinician and IT leaders have moved forward under the banner of improved patient safety and care quality, not just efficiency.

Of course, P4P is in its infancy relative to its ultimate potential for influencing patient care outcomes and the patient experience. But as more studies like this one emerge, it will be important to keep in mind what kinds of incentives trigger the kinds of clinician behaviors that policymakers, organization leaders, consumers, purchasers and payers, and even clinicians themselves, all say they want to be triggered.

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