Strategies to Improve Diabetes P4P Programs Should Consider Individual, Neighborhood Social Risks


Knowledge is limited on the potential exclusion from pay-for-performance (P4P) programs of patients living with diabetes who have with individual or neighborhood social risks.

New study results underscore the importance of individual social risk adjustment and special financial incentives in disease-specific pay-for-performance (P4P) programs, with researchers suggesting strategies for improving program adherence ought to consider both individual and neighborhood social risks for patients living with diabetes.

The study was carried out in Taiwan and findings were published in Social & Science Medicine.

Although enrollment in and adherence to a diabetes P4P program can lead to beneficial processes and outcomes of diabetes care, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks.

Value-based P4P programs serve as a financial incentive to reward health care providers to reach predefined performance targets, researchers explained. “It has been widely implemented worldwide to improve the quality of care and control of health care spending,” they added.

In the current study, investigators assessed data from Taiwan’s 2009-2017 population based National Health Insurance Research Database, the 2010 population and housing census, and income tax statistics from 2010. They identified study populations from 2012 to 2014.

The first cohort included 183,806 patients with newly diagnosed type 2 diabetes (T2D; mean [SD] age, 56.48 [13.12] years) and had undergone follow up for 1 year, the researchers said. The second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment.

In total, 80,069 patients (43.56%) were enrolled in the diabetes P4P program, and 103,737 (56.44%) patients did not participate.

Analyses revealed:

  • Patients with T2D and with higher individual social risks were more likely to be excluded from the P4P program
  • Those with higher neighborhood-level social risks were slightly less likely to be excluded
  • Patients with T2D and the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one

Exclusion from the program was also significantly linked with patients’ gender, age Deyo–Charlson Comorbidity Index, and Diabetes Complications Severity Index.

The research marks the first study, to the authors’ knowledge, that examines the impact of individual- and neighborhood-level social risks on the exclusion from and adherence to the diabetes P4P program under a single-payer health system with a high-powered inventive in narrow outcome-based payment models, where physicians hold the power to enroll preferred patients in programs.

“In Taiwan, the yearly diabetes P4P cost accounted for 44% of the total expenditure in diabetes care in 2020,” authors wrote.

Findings also suggest social risk adjustment should be included in value-based reimbursement schemes to avoid risk selection and special financial incentives for providers to improve health equity and clinical outcomes for the most vulnerable patients may prevent social risk selections

The study only addressed process indicators, marking a limitation. Also, patient social risks were also only measured via income as opposed to the socioeconomic status index that incorporates income, education level, and occupational status. P4P incentive structures also differ between countries, meaning results may not be generalizable to other programs in different countries.

“Our results point to the importance of individual social risk adjustment and special financial incentives in P4P programs,” the authors concluded. “Policy makers in Taiwan should carefully surveil gaps in the coverage of poor patients in the diabetes P4P program and scrutinize the adherence to diabetes treatment of patients with low incomes and living in deprived areas to reduce health inequalities.”


Tsai W-C, Huang K-H, Chen P-C, Chang Y-C, Chen MS, Lee CB. Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single payer health system. Soc Sci Med. Published online May 3, 2023. doi:10.1016/j.socscimed.2023.115930

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