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Table 5 Final version of the P4P typology

From: A reporting framework for describing and a typology for categorizing and analyzing the designs of health care pay for performance schemes

ITEM 1: Who received the incentive? Did Individuals or Groups receive the incentive?
 Criteria for judging Individuals • If the incentives are paid directly to individual health workers/clinicians/doctors only
• If individual health worker/clinician/doctor’s income is supplemented as a result of the incentive (e.g. reflected in the rise of personal income) only
 Criteria for judging Groups (including schemes where individuals and groups are paid bonuses) If the incentive is paid to a group or an organization in which individual clinicians may or may not benefit from the incentive directly
Groups include any of the following
• Hospital
• Clinical team
• General physician (GP) practice
• NGO
• Levels of government
• Faith based organizations
ITEM 2: Type of incentive Was the incentive in the form of Fines or Bonuses?
 Criteria for judging Fines If the incentive is negative in the form of reduction in expected payments, penalty, punishment etc. In some cases, bonuses may or may not be paid.
 Criteria for judging Bonuses If incentive is in the form of increase in payments, bonus, gifts etc. with NO fines levied
ITEM 3: Size of the incentive Was the size of the incentive small or large?
 Criteria for judging Small If the incentive in the P4P program is smaller than 5% of any one of the following:
• Salary of individual clinician/health worker/doctor
• Anticipated payments (to the health facility/hospital/clinical team) such as budgets (total budget or budget for the particular intervention in question), fee for service (FFS) and capitation
 Criteria for judging Large If the incentive in the P4P program is 5% and above of any one of the following:
• Salary of individual clinician/health worker/doctor
• Anticipated payments (to the health facility/hospital/clinical team) such as budgets (total budget or budget for the particular intervention in question), fee for service (FFS) and capitation
ITEM 4: Perceived Risk of not earning the incentive: High risk or low risk? (based on: Timing of payment after achieving targets (time lag), Domain of performance measure, and Performance measure (payment scale)
 Criteria for judging High risk If the P4P program has 2 or more of the following features
• If incentive payment (or penalty) is made after 4 months after measurement and confirmation of performance (long time lag)
• If the domain of performance measure was mostly out of clinicians control
• If the perofmance measure (payment scale) is a relative measure
 Criteria for judging Low risk If the P4P program has 2 or more of the following features
• If incentive payment (or penalty) is made before or at 4 months after measurement and confirmation of performance (short time lag)
• If the domain of performance measure was mostly within the clinicians’ control
• If the performance measure (payment scale) is an absolute measure
Note: It is possible to judge the risk of the program if one feature is missing/unclear. For example, if the time lag for payment is short and the domain of performance measure was mostly within the clinicians’ control. We can judge from this information that the risk is low even when there is little or no information about the performance measure
Timing of payment after achieving targets (time lag): was it short or long?
 Criteria for judging short If incentive payment (or penalty) is received not more than 4 months after measurement and confirmation of performance
 Criteria for judging long If incentive payment (or penalty) is received more than 4 months after measurement and confirmation of performance
Domain of performance measured Was the domain of performance measured within clinicians’ control or out of clinicians’ control?
 Criteria for judging within clinicians control If incentive payments to health service providers are mostly/only based on processes and structures e.g. number of children immunized, routine measurement of blood pressure of patients every month, number of referrals made, rate of cancer screening
 Criteria for judging out of clinicians control If incentive payments to health service providers depend on achieving a change in health outcomes e.g. reduction in mortality rates from a specific disease, blood pressure reduction, patient experience etc.
Note: sometimes, incentive programs contain a mixture of processes and outcomes. However, one category out of the two is usually predominant. For example a program with 6 process measures and 2 outcome measures. You will have to judge what category it falls into by deciding which category is predominant and for this example, the incentive program falls within the clinicians control because the process measures are predominantly more than the outcome measures.
Performance measure (payment scale) Absolute or relative measure?
 Criteria for judging Absolute measure If incentive is paid (fine levied) to the health service provider that based on their performance, not relative to how other health providers perform.
For example,
• Improvement in performance typically improvement from some baseline measure, using performance score/ performance points achieved
• Achieving performance at/above a predetermined target
• e.g. incentive paid per patient immunized, or 70% improvement from baseline
 Criteria for judging Relative measure If incentive payment is based on the performance of health service providers, relative to that of other providers.
For example,
• If bonuses are paid for to health service providers in a specific performance rank e.g. the providers above the top quartile of performance.
• And/or
• If fines are levied on health service providers in certain ranks usually the bottom ranks e.g. the providers below the lower quartile of performance