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The American Journal of Accountable Care June 2015
Communication and Accountable Care
Christopher H. Mathis, JD, MPA, Michael E. Chernew, PhD
Accountable Care Organizations: A Model for the Future
Anthony D. Slonim, MD, DrPH; and Kirk Gillis
Do You Speak My Language? When Patient Care Meets Cost-Effectiveness
José A. Pagán, PhD; and Brendan Saloner, PhD
The Healthcare Revolution Will Be Digitized
Brian Ahier
AJAC Interviews Sachin H. Jain, MD, MBA, Chief Medical Officer, CareMore
Laura Joszt, MA
Stay East, Young Man
Matthew Hayward, BA; and Sachin H. Jain, MD, MBA
Lessons From CareMore: A Stepping Stone to Stronger Primary Care of Frail Elderly Patients
Christine A. Sinsky, MD; and Thomas A. Sinsky, MD
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Impact of Incentives to Improve Care for Primary Care Patients
Lise Rybowski, MBA; Dale Shaller, MPA; Susan Edgman-Levitan, PA; and Paul D. Cleary, PhD
Exploring the New Rules of Patient Engagement: AJMC's ACO and EHDC Spring 2015 Live Meeting
Mary K. Caffrey
Patient-Centered Teamwork in Care Transitions
Niharika Khanna, MD, MBBS, DGO; Fadia T. Shaya, PhD, MPH; Viktor V. Chirikov, MS; David Sharp, PhD; and Ben Steffen, MA
Meaningfully Engaging Patients in ACO Decision Making
Matthew DeCamp, MD, PhD; Jeremy Sugarman, MD, MPH, MA; Scott Adam Berkowitz, MD, MBA

Impact of Incentives to Improve Care for Primary Care Patients

Lise Rybowski, MBA; Dale Shaller, MPA; Susan Edgman-Levitan, PA; and Paul D. Cleary, PhD
Multiple factors can impact the effectiveness of financial incentives intended to encourage primary care providers to improve patient experiences.
Whether incentive programs lead to more effective improvement activities by medical practices remains an open question. We assessed the impact of a pay-for-performance program designed to improve patients’ experiences with primary care and identified the factors that influenced the outcomes.

Study Design and Methods: We conducted telephone interviews with clinical and administrative leaders of 8 physician practices that had been identified by a major health insurance plan as needing to improve on their past scores on a patient experience survey.

Results: The financial incentive had almost no effect on the priorities or activities of the medical practices. Few practice leaders were aware of the incentive. All were familiar with local efforts to improve patients’ experiences and some maintained that focus over time, but not because of the ongoing system-level initiative. The effectiveness of the incentive program was limited by the program design, the improvement goals, the timing of progress measurement, and a lack of ongoing communication about the program’s purpose, available support, and goals. Medical practice leaders’ understanding of the program and its goals was limited; providers infrequently used the free educational programs available; and other initiatives may have taken priority.

Conclusions: These findings suggest that if system-level incentives are to improve care quality, they must be designed carefully to reach the audience responsible for improving care, to motivate organizational change, and to support ongoing communications with practice leaders.
Both public and private payers have been expanding the use of pay-for-performance (P4P) programs that encourage improvements in primary care by linking financial rewards to evidence of higher quality. These programs have evolved in response to concerns that many weaknesses in the healthcare system are a result of the way providers are compensated. Whether P4P programs lead to improvements in the quality of healthcare remains an open question. There are relatively little data on the influence of such programs1,2 and the available evidence on their effectiveness is mixed.3 Studies that show an impact have found modest effects4; these studies have focused on measures of clinical process and intermediate outcomes.5 Given the increasing attention to patient experience measures in value-based purchasing programs, such as the CMS Medicare Shared Savings Program,6 it is important to understand the effectiveness of P4P strategies in driving improvements in patient experience.

The purpose of this study was to assess whether and how an incentive program for a large provider network to improve primary care patients’ experiences affected the priorities and activities of medical practices. In this article, we describe the program and use the framework proposed by Van Herck and colleagues to assess several factors that might have affected its results.7 The review of 128 evaluation studies by Van Herck and colleagues concluded that the impact of P4P programs can be influenced by the program’s context as well as various design choices, including the ways in which quality is measured, the quality goals and target, the nature of the incentives, how the program is implemented and communicated, and how the effects are evaluated. This framework offers useful insights into the factors that may have undermined or facilitated the effectiveness of the P4P program in driving improvements in patient experience.


In 2004, a large healthcare network negotiating with a major health insurance plan in its market8 agreed to a 5-year P4P program that would financially reward practices for attaining specified goals. An improvement in patients’ experiences with primary care was one of the performance goals for the second phase of the contract (2007-2009). The incentive was that part of a “revenue withhold” would be returned to the network if lower-performing primary care practices improved their scores on a standardized patient experience survey adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Survey.9 The program included 96 primary care practice sites in the network that scored below the statewide mean on 1 or more measures of patient experience. The total value of the withhold tied to patient experience was about $5 million.

To help the low-performing practices improve patient experience, the network contracted with an internal center with expertise in primary care improvement. The center supported the practices in developing priorities and improvement plans and offered free educational and consulting services designed to help the practices improve the domains of patient experience addressed by the survey.

Under the terms of the P4P contract, the network was required to submit improvement plans for 95% of low-performing practices. In the third year, the practices were expected to achieve specified improvements in performance. The percentage of the withhold that would be available to the practices ranged from 25% to 100%, depending on the percentage of practices that met their target based on the 2009 survey results. If fewer than 55% of practices met the target, none of the withheld revenue would be returned.


In 2008, 2 of the authors (LR and DS) conducted in-person and telephone interviews with several individuals involved in the P4P program from the health plan, the provider network, the internal consulting center, and an independent organization that gathers and reports the survey results. These interviews elicited information about the P4P program as well as perspectives on the program’s development, purpose, and feasibility.

The 96 physician practices that met the criteria for participation in the P4P program were affiliated with 16 large organizations that manage the practices. To select potential interviewees for this study, we first identified the 2 survey topics chosen as improvement priorities by the most practices: doctor-patient communication and office staff courtesy and respect. Our sample consisted of the 31 practices that chose either of the 2 topics; these practices represented 11 of the large physician organizations.

The 31 practices were divided into 2 groups: those that met the target (16) and those that did not (15). The original goal was to interview 2 practices that met the goal and 2 that did not for each of the 2 topics. However, it was not possible to identify practices in all 4 categories because all of the practices that focused on communication met their target. Thus, we selected practices that represented a mix of topics (ie, both communication and office staff), a mix of results for the office staff measure, and a mix of large physician organizations.

The study protocol was approved by the Yale Human Investigations Committee. All subjects knew that we were conducting research and agreed to be interviewed.

In 2011, we invited 17 practices by e-mail and phone to participate in 30- to 60-minute telephone interviews. If a practice declined to participate, another practice was selected and contacted. In total, the authors interviewed clinical and administrative leaders of 8 medical practices, 1 of which included multiple sites. These sites represented approximately one-third of the medical practices focusing on the 2 topics: 11 of the 31 practice sites and 5 of the 16 large physician organizations.


The interviews with the clinical and administrative practice leaders revealed a low level of awareness of the P4P program. Only 1 of the interviewees knew that the practice had a financial incentive to improve patient experience scores; none was aware that the network did not receive the withheld dollars tied to patient experience because slightly fewer than 55% of the participating practices had met their performance target.

Moreover, the practice leaders were not aware that the goal of improving patient experience was part of an ongoing network initiative. While they knew about the network’s initial efforts to focus their attention on patient experience, those that maintained that focus over time did not characterize their efforts as part of a systemwide initiative to achieve specified goals.

While all the practices were aware of the public report of patient experience survey results, several had never looked at the report and almost none had used it. To assess their performance, they relied on their own survey results or those collected for their practice by the provider organizations with which they were affiliated. The differences between the publicly reported measures and scores and those from other sources caused confusion and frustration.

The practice leaders also varied significantly in their awareness, understanding, and use of the free educational and consulting services. While some took full advantage of the offerings, others were either unaware of the services or uninterested. Also, even though several practice leaders indicated that doctors or staff had participated in and benefited from at least 1 educational event, not all of them were clear on what organization sponsored the events or that the services were related to the incentive to improve patient experience.

Because of the requirement to produce improvement plans, the P4P program initially succeeded in capturing the practices’ attention. However, the long-term incentive generally did not lead to an ongoing focus on patient experience. While a few practices continued to plan and implement improvement strategies, most turned their attention to other challenges, noting that patient experience was only one of many issues that require their attention and resources.

Factors Affecting Program Success

Categorizing the interview comments according to the framework of Van Herck and colleagues7 suggests why the P4P program failed to bring about a sustained effort to improve patient experience.

The External Context for a P4P Program

The network-level incentive to improve patient experience took place in a context that placed conflicting demands on practices. First, this program coincided with a statewide health reform effort that resulted in insurance coverage for most residents. For many practices, the subsequent pressure to meet the demand for primary care services overwhelmed their ability to focus on other needs. All of the practices noted that improving patients’ access to care and information had been one of their highest priorities in recent years. While access to care is an element of patient-centered care, it was not the domain that these practices had committed to improve under the P4P program. Thus, to some extent, the practices’ commitment to improving one aspect of patient experience was competing with the urgent need to improve another aspect.

Constant competition for the attention of administrative and clinical leaders was also a key part of the external context. Within the network, the goal to improve patient experience was just 1 of several P4P goals. When measures and goals change from year to year, it is a significant challenge for healthcare leaders to maintain a focus on any improvement target over time.5,10 In addition, other health plans and payers were seeking improvements in specific areas. Health plans in the state had been implementing performance incentives for several years: a 2004 survey found that 89% of the medical groups had a P4P incentive in at least 1 commercial plan contract. Over a third of the surveyed groups reported that their incentives were tied to their performance on patient satisfaction surveys.11

Finally, organizational identity and affiliation contributed to the context for the participating medical practices.12 None of the interviewees said that that their improvement work was focused on a goal shared with primary care practices across the provider network. To the extent that they referred to anything other than their own practices, it was their affiliation with a large health system or medical group. However, the goals of the network’s P4P contract were not always aligned with the goals and programs of these other, more proximate organizations.

Friedberg et al found that a majority of medical groups in the study state were working to improve patient experience: 61% reported groupwide improvement efforts and 22% were focused on improving care from low-scoring physicians or practice sites.13 Those groups were more likely than other groups to have some financial incentive to improve. Thus, it is likely that at least some of the practices affected by the network-level program were also participating in a group-level program. However, the improvement targets and strategies for the medical groups were not identical. Although both programs focused on communication, for example, the improvement initiatives at the group level did not emphasize doctor-patient communication; they were primarily focused on organizational factors, such as redesigning office work flow, training nonclinicians, using electronic health records, and reassigning staff responsibilities.13

The Quality Measure

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