Healthcare System Effects of Pay-for-Performance for Smoking Status Documentation

Published Online: July 18, 2013
Gina R. Kruse, MD; Yuchiao Chang, PhD; Jennifer H. K. Kelley, RN, MA; Jeffrey A. Linder, MD, MPH; Jonathan S. Einbinder, MD, MPH; and Nancy A. Rigotti, MD
Objectives: To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system’s patients.

Study Design: Three commercial insurers simultaneously adopted P4P incentives to document  smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients’electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility.

Methods: The P4P-eligible patients were compared primarily with a subset of non–P4P-eligible patients who resembled P4P-eligible patients and also with all non–P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends.

Results: Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement  from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non–P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009).

Conclusions: A P4P incentive targeting a minority of a healthcare system’s patients stimulated adoption of a systemwide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet “meaningful use” standards for EHRs.

Am J Manag Care. 2013;19(7):554-561
Routine documentation of smoking status improves clinicians’ delivery of tobacco treatment and is mandated in “meaningful use” standards for electronic health records butcan be challenging to accomplish.
  • A payer-sponsored pay-for-performance incentive prompted systemwide action by the healthcare system, resulting in improved documentation among both targeted and nontargeted patients.

  • The effect was greatest among targeted patients, suggesting the financial incentive added value as well as prompting the reminder.

  • Combining a performance incentive with an electronic reminder could help healthcare systems to improve treatment for tobacco use and enable population health interventions for smokers.
Smoking kills more than 440,000 people in the United States annually and remains the leading preventable cause of death.1,2 Despite the availability of effective treatments for tobacco dependence, physicians assess smoking at only 63% of visits and  offer counseling to only 21% of smokers.3 Identification and documentation of smoking status are the first steps to addressing tobacco dependence and have been shown to increase physicians’ delivery of treatment.1 Clinical practice guidelines for treating tobacco dependence recognize the importance of documentation and call for routine smoking status screening and documentation by healthcare systems. The US government’s “meaningful use” electronic health record (EHR) incentive program requires smoking status identification in a coded field.1,4 Yet achieving a high rate of smoking status documentation is a challenge for many healthcare systems.5

Efforts to improve smoking status documentation have included electronic or paper-based reminders, performance feedback, and a simple vital sign stamp.1,6-16 Pay-for-performance (P4P) incentives have been used in some systems to promote delivery of guideline-based tobacco treatment, or as a component of broader quality improvement efforts.7-9,17,18 These studies have examined performance incentives for various guideline-based treatment activities, including smoking status documentation, documentation of physician-delivered counseling, referral to telephone counseling, and payments to providers for patients’ tobacco abstinence. Prior studies of P4P for smoking status documentation were limited to US physician groups or healthcare delivery  systems outside the United States.7-9,17,18 Relatively little is known about the effects of P4P programs in large, multipayer, integrated US healthcare delivery systems in which P4P incentives do not apply to all patients in the system. A payer-sponsored P4P incentive in a multipayer system may only be effective for the patient population to whom it applies. However, practice changes stimulated by a targeted P4P measure can have broader benefits that improve documentation and treatment delivery for targeted and non-targeted patients.

A P4P incentive that was introduced in 2010 in a large multipayer healthcare delivery system rewarded practices for documenting the smoking status of patients with specific commercial insurers and 3 chronic diseases. The organization’s multiple payers and diverse provider groups with varied practice styles and patient populations make standardized quality improvement efforts especially challenging. Our objective was to study the effect of a targeted, payer-sponsored P4P incentive payment on smoking status documentation across the healthcare system.


Study Setting

Partners HealthCare Inc is a large integrated healthcare delivery system in eastern Massachusetts whose provider network, Partners Community HealthCare, Inc (PCHI), represents more than 5000 primary care and specialist physicians, and works with multiple payers including commercial insurers, Medicare, and Medicaid.19,20 All PCHIaffiliated practices use one of several different EHRs. This study was restricted to the practices using the system’s predominant EHR, the Longitudinal Medical Record, a locally developed system used by 63% of PCHI practices that was first implemented in 1998. Active providers have been using the EHR for a median of 3.5 years (interquartile range, 1.4-6.7 years). It includes progress notes, laboratory results, medication lists, electronic prescribing, and a variety of clinical reminders.21


Since 2001, PCHI has negotiated P4P contracts with 3 large, commercial, not-for-profit insurers who collectively cover the majority of commercially insured patients.20 Starting on January 1, 2010, the 3 commercial insurers contracted separately with PCHI to pay practices for achieving a target smoking status documentation rate among a group of highrisk patients. The incentive was implemented using a withheld amount that was returned to practices meeting the prespecified target. Selected targets must meet agreed-upon standards of care that are easy to measure, likely to improve quality of care, and involve enough patients for statistical reliability.20 The amount of payment to practices depended on revenue from P4P-eligible patients and ranged from 3% to 4.8% of practice revenue from the participating insurers for all P4P measures, and $3.8 million was at risk in PCHI for the smoking status documentation measure. Based on the preincentive documentation and the national guideline recommending that patients be screened at every visit, the target documentation rate was set at 80%.1 Documentation was measured among eligible patients over a 2-year span (January 1, 2010, to December 31, 2011), with payment at the end ofthe first year for progress toward the goal and at the end of the second year for reaching the goal.

Eligible patients were adults (>18 years old) who made a visit to a PCHI outpatient practice during the measurement period, were insured by 1 of 3 participating commercial insurers, and had a high risk chronic condition (hypertension, diabetes, or coronary heart disease). The eligible visit could have been to any PCHI specialist or primary care practice in academic-affiliated or community-based practices.

To help practices reach the 80% target, PCHI added an organizationwide clinical decision support tool consisting of a clinical reminder to document smoking status in all patients’ EHRs. The nontargeted EHR reminder was implemented concurrently with the P4P program on January 1, 2010. The EHR-based reminder was designed so that clicking the reminder linked to the coded field for smoking status documentation. Documentation could also be accessed in the EHR through a vital signs entry screen or a health monitoring grid that tracks preventive care and chronic disease management.


To measure the effects of the P4P program on prevalent smoking status documentation, we conducted an observational study before and after P4P implementation. We compared smoking status documentation between the group of high-risk patients who were targeted by the P4P incentive and (1) all non–P4P-eligible patients and (2) a subset of non– P4P-eligible patients who most resembled the P4P-eligible group by having commercial insurance and the same targeted diagnoses as P4P-eligible patients. The study was approved by Partners HealthCare System’s Institutional Review Board.

Data Source

We used data from the EHR to estimate the effect of the P4P incentive on smoking status documentation. We identified adult patients (>18 years old) who had an office visit with a PCHI provider before (2008-2009) or after (2010-2011) the P4P incentive. We extracted patient data including smoking status, age at the visit, sex, race/ethnicity and primary language entered at registration, insurance, primary care proWe identified the 3 high-risk, chronic conditions included in the P4P incentive. Patients were designated as having the chronic condition if the diagnosis was entered into the EHR before the qualifying visit for that period. Hypertension was defined as a coded entry on the problem list, with the last systolic blood pressure greater than 135 mm Hg or the last diastolic blood pressure greater than 85 mm Hg. Coronary heart disease was based on coded problem list entries of coronary arteriosclerosis, angioplasty, stent placement, coronary artery bypass graft, or myocardial infarction. Diabetes was based on a coded problem list entry of diabetes or a glycated hemoglobin value greater than 7.0%.

We included provider-level demographic data (age and sex) for the primary care provider designated in patients’ EHR registration at the start of the study year. Provider-level data were taken from a master provider list maintained by PCHI. Some provider-level data were missing; for these, we included a dummy variable for missing data.


Smoking status documentation is designated in a structured field in the EHR as “active smoker,” “past smoker,” and “never smoker.” To measure the change in documentation before and after implementation of the P4P incentive, we calculated prevalent documentation of smoking status on December 31, 2009, and December 31, 2011. To match the 2-year duration of the P4P program, we pooled patients with at least 1 visit in the 2 years before (2008-2009) and the 2 years after (2010-2011) the P4P implementation. We hypothesized that documentation prevalence would not be significantly different from year to year before P4P implementation, and confirmed this hypothesis prior to pooling.

Data Analysis

We calculated the unadjusted prevalence of smoking status documentation before and after the P4P incentive among P4P-eligible patients (as defined above), among all non–P4P-eligible patients, and among a subset of the non– P4P-eligible patients who were comparable to the eligiblepatients in having had a visit to a PCHI provider and a qualifying  high-risk chronic condition, but a nonparticipating commercial insurer. We measured the prevalence of documentation among providers stratified by the proportion of P4P-eligible patients seen.

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