The Effect of a PPO Pay-for-Performance Program on Patients With Diabetes

A pay-for-performance program in a preferred provider organization setting may significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes.

Objectives

: To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus.

Study Design

: Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006.

Methods

: We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics.

Results

: Patients with diabetes who saw P4Pparticipating physicians were more likely to receive quality care than those who did not (odds ratio, 1.16; 95% confidence interval, 1.11-1.22; P <.001). Patients with diabetes who received quality care were less likely to be hospitalized than those who did not (incident rate ratio, 0.80; 95% confidence interval, 0.80-0.85; P <.001). During 1 year, there was no difference in hospitalization rates between patients with diabetes who saw P4P-participating physicians versus those who did not. However, patients with diabetes who saw P4P-participating physicians in 3 consecutive years were less likely to be hospitalized than those who did not (incident rate ratio, 0.75; 95% confidence interval, 0.61-0.93; P <.01).

Conclusions

: A P4P can significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes in a PPO setting. Although it is possible that the differences observed between P4P-participating physicians and non—P4P-participating physicians were due to selection bias, we found no significant difference in the receipt of quality care between patients with diabetes who saw new P4P-participating physicians versus non–P4P-participating physicians during the baseline year. Further research should focus on defining the effect of P4Ps on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels.

(Am J Manag Care. 2010;16(1):e11-e19)

A pay-for-performance program in a preferred provider organization setting may significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes.

  • Without concurrent quality improvement interventions such as diabetes disease management programs, a pay-for-performance program may increase quality-of-care processes but fail to improve outcomes.
  • Further research should focus on defining the effect of pay-for-performance programs on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels and on quantifying the additional benefits of quality improvement activities such as diabetes disease management programs.

Author Affiliations: From Health Benchmarks, Inc, IMS Health (JYC, HT, JCB), Woodland Hills, CA; Hawaii Medical Service Association (DTJ, KAH, RSC), Honolulu, HI; Office of Public Health Studies (DTJ), University of Hawaii, Manoa, HI; and the UCLA School of Public Health (APL), Woodland Hills, CA.

Funding Source: This study was supported by the Hawaii Medical Service Association, Honolulu, HI.

Author Disclosure: Dr Taira Juarez, Ms Hodges, and Dr Chung are employees of the Hawaii Medical Service Association, the health plan whose physician incentive program was analyzed in this study. The other authors (JYC, HT, JCB, APL) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. The Hawaii Medical Service Association reviewed the manuscript before submission for publication and contributed considerable information about the program and administrative data for analysis but had no influence on the study design, analysis, or results of the manuscript.

Authorship Information: Concept and design (JYC, HT, DTJ, KAH, RSC, APL); acquisition of data (RSC); analysis and interpretation of data (JYC, HT, DTJ, RSC); drafting of the manuscript (JYC, DTJ); critical revision of the manuscript for important intellectual content (JYC, DTJ, JCB, KAH); statistical analysis (JYC, HT, DTJ); obtaining funding (JYC, RSC); administrative, technical, or logistic support (JYC, KAH, JCB, APL); and supervision (JYC, KAH, JCB, RSC, APL).

Address correspondence to: Judy Ying Chen, MD, MSHS, Health Benchmarks, Inc, IMS Health, 21650 Oxnard St, Ste 550, Woodland Hills, CA 91367. E-mail: judy.chen@us.imshealth.com.

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

2. Baker G, Carter B. Introduction to Case Studies in Health Plan Pay-for-Performance. Washington, DC: Atlantic Information Services; 2004.

3. Rosenthal MB, Landon BE, Normand SL, Frank RG, Epstein AM. Pay for performance in commercial HMOs. N Engl J Med. 2006;355(18):1895-1902.

4. Terry K. Pay for performance: how fast is it spreading? http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=190108. Accessed August 11, 2008.

5. Centers for Medicare & Medicaid Services. Medicare “pay for performance (P4P)” initiatives. http://www.cms.hhs.gov/apps/media/pressrelease.asp?counter=1343. Accessed August 11, 2008.

6. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005;294(14):1788-1793.

7. Fairbrother G, Hanson KL, Friedman S, Butts GC. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates. Am J Public Health. 1999;89(2):171-175.

8. Fairbrother G, Siegel MJ, Friedman S, Kory PD, Butts GC. Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial. Ambul Pediatr. 2001;1(4):206-212.

9. Roski J, Jeddeloh R, An L, et al. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Prev Med. 2003;36(3):291-299.

10. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006;145(4):265-272.

11. Felt-Lisk S. Monitoring quality in Medicaid managed care: accomplishments and challenges at the year 2000. J Urban Health. 2000;77(4):536-559.

12. Hillman AL, Ripley K, Goldfarb N, Nuamah I, Weiner J, Lusk E. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Am J Public Health. 1998;88(11):1699-1701.

13. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297(21):2373-2380.

14. Grady KE, Lemkau JP, Lee NR, Caddell C. Enhancing mammography referral in primary care. Prev Med. 1997;26(6):791-800.

15. Nahra TA, Reiter KL, Hirth RA, Shermer JE, Wheeler JR. costeffectiveness of hospital pay-for-performance incentives. Med Care Res Rev. 2006;63(1 suppl):49S-72S.

16. Curtin K, Beckman H, Pankow G, Milillo Y, Green RA. Return on investment in pay for performance: a diabetes case study. J Healthc Manag. 2006;51(6):365-376.

17. Gilmore AS, Zhao Y, Kang N, et al. Patient outcomes and evidencebased medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program. Health Serv Res. 2007;42(6, pt 1):2140-2159.

18. Coleman K, Reiter KL, Fulwiler D. The impact of pay-for-performance on diabetes care in a large network of community health centers. J Health Care Poor Underserved. 2007;18(4):966-983.

19. Chung RS, Chernicoff HO, Nakao KA, Nickel RC, Legorreta AP. A quality-driven physician compensation model: four-year follow-up study. J Healthc Qual. 2003;25(6):31-37.

20. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27.

21. Healthcare Cost and Utilization Project (HCUP). Comorbidity Software, version 3.3. http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp. Accessed July 28, 2008.

22. Colhoun MH, Betteridge DJ, Durrington PN, et al; CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004;364(9435):685-696.

23. American Diabetes Association. Standards of medical care in diabetes: 2008. Diabetes Care. 2008;31(suppl 1):S12-S54.

24. Casalino LP, Elster A, Eisenberg A, Lewis E, Montgomery J, Ramos D. Will pay-for-performance and quality reporting affect health care disparities? Health Aff (Millwood). 2007;26(3):w405-w414.

25. Mandel KE, Kotagal UR. Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161(7):650-655.

26. Cutler TW, Palmieri J, Khalsa M, Stebbins M. Evaluation of the relationship between a chronic disease care management program and California pay-for-performance diabetes care cholesterol measures in one medical group. J Manag Care Pharm. 2007;13(7):578-588.

27. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004;113(5 suppl):1493-1498.

28. Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med. 1989;321(17):1168-1173.

29. Lohr KN. Use of insurance claims data in measuring quality of care. Int J Technol Assess Health Care. 1990;6(2):263-271.

30. McBean AM, Warren JL, Babish JD. Measuring the incidence of cancer in elderly Americans using Medicare claims data. Cancer. 1994;73(9):2417-2425.

31. McBean AM, Babish JD, Warren JL. Determination of lung cancer incidence in the elderly using Medicare claims data. Am J Epidemiol. 1993;137(2):226-234.

32. Nattinger AB, Laud PW, Bajorunaite R, Sparapani RA, Freeman JL. An algorithm for the use of Medicare claims data to identify women with incident breast cancer. Health Serv Res. 2004;39(6, pt 1):1733-1749.

33. O’Connor RD, Rosenzweig JR, Stanford RH, et al. Asthma-related exacerbations, therapy switching, and therapy discontinuation: a comparison of 3 commonly used controller regimens. Ann Allergy Asthma Immunol. 2005;95(6):535-540.

34. Min JK, Kang N, Shaw LJ, et al. Costs and clinical outcomes after coronary multidetector CT angiography in patients without known coronary artery disease: comparison to myocardial perfusion SPECT. Radiology. 2008;249(1):62-70.