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Table 2 General characteristics pay-for-performance schemes

From: Pay-for-performance in disease management: a systematic review of the literature

Pay-for-performance scheme Country Elements chronic care model Goal and patient population Type Incented entity Focal quality behavior Scope Motivation Scale Size Certainty Frequency and duration
Schemes in which financial incentives are granted to healthcare providers for delivering chronic care through disease management
Western New York Physician Incentive Program (WNY-PIP) [16] USA P4P simultaneously implemented with:
1. change in delivery system design (establishment of new routines in physician's office)
2. decision support (e.g. assessment tools, educating and training physician office staff, reflective information feedback )
3. self-management support (e.g. providing patient education materials)
1. To improve chronic care treatment for diabetes patients
2. To explore effectiveness of financial incentives in improving care for this patient population
3. To promote new routines in physician's office
Ultimate goal: improve patient health
Reward Individual: Physician Process:
6 clinical QI based on ADA clinical guideline Outcome: 3 patient outcome indicators
Selective: health plans pay financial incentives based on composite score on process and outcome indicators N.A. Absolute
1. scoring above predetermined target on composite score based on performance on process and outcome indicators
2. 50% improvement in composite score
Size of reward depends on weighted composite score.
Actual payments varied from $3,000 till $12,000 (2003)
13 of 21 physician earned a financial reward. Annually
Performance Based Incentive Program (PBIP) Highmark Blue Cross Blue Shield [12, 17] USA P4P simultaneously implemented with:
1. decision support (e.g. up to date clinical physician guidelines, reflective information feedback, regular review by medical management consultant)
2. clinical information system (e.g. sharing practice specific data with other physicians for benchmarking)
Encourage healthcare providers to deliver best possible quality care and encourage coordinated care (patient population unknown) Reward Group: physician groups (not further specified) Structure: electronic connectivity,
Process: clinical quality
Outcome: patient satisfaction
N.A. N.A. Relative: physician groups are rewarded if they exceed other physicians (in and out of the program) in performance on structure, process, and outcome indicators N.A. N.A. N.A.
Partners Community Healthcare Inc./Brigham and Women's Physicians Organization pay-for-performance program (BWPO-P4P) [18, 19] USA P4P simultaneously implemented with:
1. decision support (e.g. non-physician staff contact patients and physicians to improve compliance with practice guidelines)
2. change in delivery system design (e.g. central diabetes patient outreach coordinator tracking data and performance progress and checking compliance of patients; home visits)
3. clinical information system (adoption of electronic medical records and claims that track patient screening data (HEDIS) for e.g. benchmarking; central office sending reminder letters).
Improve quality and efficiency of care within the organization with regard to inpatient admissions, radiology, diabetes care, and asthma care.
Only P4P scheme for diabetes and asthma care are relevant for our review.
Penalty: programs operate by withholding 10% of physician/hospital fees and returning those fees based on whether quality and efficiency targets are achieved Group: network of primary care physicians, ophthalmologists, and staff Process: clinical quality according to HEDIS measures Outcome: achieving target outcomes
Shift from performance targets that focus on process indicators to targets that focus on outcome indicators
Selective: incentives based on performance on process and outcome indicators. N.A. Relative, withhold is returned if network:
1. scores above state or national 90th percentile of HEDIS targets
2. improves baseline performance Some regional service organizations provide additional incentives directly to physicians whose patients meet HEDIS targets and many regional service organizations provide bonuses for non-clinical staff members who are critical to success of these programs
Portion of withholding that will be returned depends on performance on HEDIS measure (in 2006: moderate-volume primary care physician practices could earn additional $3000 to $5000 per physician if network met P4P HEDIS targets) N.A. Annually
Bridges to Excellence program (BTE) [12, 2023] USA P4P to stimulate implementation of:
1. self-management support (e.g. patient education, shared decision-making)
2. decision support (e.g. clinical standards set by NCQA/ADA)
3. clinical information system (e.g. adoption of electronic systems to maintain medical records documenting care delivery for reflective information feedback/benchmarking)
Create significant improvements in quality of asthma care, cardiac care, congestive heart failure care, coronary artery disease care, depression care, diabetes care, hypertension care, and spine care by recognizing and rewarding health care providers for implementing elements of CCM and delivering safe, timely, effective, efficient, equitable, and patient-centered care Reward: higher revenue Individual: physicians, nurse practitioners, and physician assistants certified through provider recognition program of NCQA Structure: clinicians should comply with standards for clinical information systems
Process: clinicians should comply with national standards for clinical care management, patient education and support
Selective: incentive based on whether healthcare providers meet a set of structure and process measures, which are scored to create overall program score where 60 is most often the passing grade. N.A. Absolute: incentive is provided when healthcare professionals meet certain performance measures.
Each measure has an assigned maximum available point value. Clinicians achieve points for a measure based on the % of patient sample that meets or exceeds the set thresholds for that measure.
Depends on level of performance. Size of rewards changes over time and differs between health plans that participate in Bridges to Excellence. N.A. Annually
Integrated Healthcare Association Pay-for-performance Program (IHA-P4P) [2429, 31] USA P4P to stimulate implementation of:
1. change in delivery system design (e.g. redesigning processes and creating a systematic approach to diabetes care such as registries, actionable reports, and care management processes)
2. decision support (using evidence-based national measures)
3. clinical information system (e.g. adoption infrastructure for systematic processes of care; electronic medical records, reminder systems, reflective information feedback, benchmarking).
Stimulate provider organizations to consistently demonstrate high levels of quality performance with regard to preventive care, treatment of acute conditions, and treatment of chronic conditions (asthma, diabetes, and coronary heart disease) through public recognition and financial reward
Only financial incentives for chronic conditions are relevant for our review.
Reward: provider groups earn financial rewards if they participate in the program and perform well on selected measures Group: physician groups Structure: adoption of IT enabled system to support patient care
Process: 1. clinical quality: preventive screening, treatment of asthma, diabetes, and coronary artery disease; 2. coordinated diabetes care
Outcome: patient experience
Measure set is dynamic with new measures added each year.
Selective: health plans pay financial incentives based on composite score on established structure, process, and outcome measures.
Composite score is calculated and then weighted: clinical quality 55%, patient experience 25%, coordinated diabetes registry 5%, IT enabled systemness 15%, resulting in overall performance score
N.A. Absolute:
Physician groups may receive incentive incremental financial payment for scoring in any of the category measures as long as the group scores in the appropriate percentile ranking as determined by the health plan.
Each health plan that participates in IHA-P4P scheme determines its own budget and methodology for calculating and distributing payments to physician groups. On average about 1% of base income of physician group (in 2009). N.A. Annually
Practice Incentive Program Diabetes Incentive (PIP-DI) [3538] Australia P4P simultaneously implemented with:
1. self-management support (e.g. patient education in line with so-called diabetes and asthma cycles of care: minimum requirements to diabetes care based on national guidelines)
2. decision support (e.g. working in line with diabetes and asthma cycles of care), including support from regional primary care organization to encourage uptake
3. clinical information system (e.g. improvement of IT infrastructure)
To encourage GP's to effectively manage clinical diabetes and asthma care, mental health care and cervical screening. Only financial incentives for diabetes and asthma care are relevant for our review.
Practices had to become accredited against standards of RACP.
Reward: incremental income Group: GP practice Structure: use of patient register and recall/reminder system Process: delivery of care according to national guidelines Selective: incentives based on compliance with structure and process measures N.A. Absolute: incentive is provided when GP practices meet requirements Diabetes
$1 per standardized whole patient equivalent (SWPE) when using patient register and recall/reminder system (sign-on payment)
$20 per patient to practices where at least 2% of patients are diagnosed with diabetes and GPs have completed a cycle of care for at least 20% of these patients (outcomes payment)
$40 per patient per year for each completed cycle of care (service incentive payment)
Asthma $0.25 per SWPE to practices that implement a cycle of care for patients with moderate to severe diabetes (sign-on payment)
$100 per patient per year for each completed cycle of care for patients with moderate to severe asthma
N.A. Quarterly
Annually
Quarterly
Once
Quarterly
Medicare Physician Group Practice Demonstration (MPGPD) [32, 33] USA P4P simultaneously implemented with:
1. self-management support (e.g. patient education, active communication of patients with physicians and nurses, maintaining diet and exercise programs)
2. change in delivery system design (e.g. delegating tasks of physicians to non-physicians)
3. clinical information systems (e.g. electronic medical records, patient monitoring systems)
Quality improvement and cost efficiency of diabetes care, heart failure care, cardiac care, and preventive care at the level of the PGP Reward Group: PGP Process: clinical quality according to HEDIS measures
Outcome: clinical quality according to HEDIS measures
32 indicators are subset of CMS Quality Measurement and Health assessment Group for the Doctors Office Quality and comprise both process and outcome indicators.
Selective: Incentives based on performance on broad range of quality indicators which focused on diabetes mellitus, heart failure, coronary artery disease and hypertension, and preventive care. N.A. Absolute and relative Absolute: if cost saving ≥2% of target expenditures then 20% directly to Medicare and 80% to PGP. The portion provided to PGP is divided in cost performance payment (fixed payment) and quality performance payment.
Quality performance payment is based on absolute and/or relative performance. To earn payment, PGP must achieve for each indicator at least 1 of 3 targets: 1. achieve ≥75% compliance or HEDIS mean for the measure (absolute); 2. achieve 70th percentile Medicare level (relative); 3. demonstrate ≥10% improvement in compliance (absolute)
A shared savings provider payment model in which savings are shared between participating physician groups and the Medicare groups. A higher portion of the saving can be retained by PGP by good performance on indicators.
Size depends on score on quality indicators. In total 2 PGPs received performance payments of in total $7.3 million as their share in the total saving of $9.5 million.
2 of 10 PGP earned a reward. Annually
Schemes in which financial incentives are granted to health insurers to enroll patients in disease management programs
Incentive to stimulate sickness funds to enroll patients in disease management program (DMP-P4P) [34] Germany P4P to stimulate implementation of certified DMPs.
Information about when DMPs are classified as "certified" is limited. However, the following CCM elements are considered as important components of DMPs:
1. self-management support (e.g. patient education)
2. clinical information systems (e.g. quality management systems, feedback systems)
Stimulate sickness funds to enroll chronically ill patients (diabetes type 1 and 2, coronary heart disease, breast cancer, asthma, and COPD) in DMPs which are expected to improve quality and cost-effectiveness of healthcare for patients with chronic conditions Reward: sickness funds that set op DMPs are rewarded with additional payments from risk adjustment scheme Group: sickness funds Structure: setting-up certified disease management program General: if sickness funds set up certified DMPs and are able to enroll a high number of chronically ill patients for the relevant disease, they receive additional payments from risk adjustment scheme.
If sickness funds do not set up DMPs or if they are able to do so but are not able to enroll a high number of chronically ill patients, they will receive fewer payments from the risk adjustment scheme
N.A. Absolute: sickness funds receive higher payments for patients enrolled in certified DMP Payments from risk adjustment system. Size unknown. N.A. N.A.
  1. Notes: ADA = American Diabetes Association; CMS = Centers for Medicare and Medicaid Services; DMP = disease management program; HEDIS = Health Plan Employer Data and Information Set; N.A.= not available: information about these characteristics was not documented in the papers that we retrieved through our search process and/or could not be obtained from relevant websites; NCQA = National Committee for Quality Assurance; PGP = physician practice group; P4P = pay-for-performance; QI = quality indicators; RACP = Royal Australian College of General Practitioners.