Pay-for-performance in safety net settings: issues, opportunities, and challenges for the future.

A major trend among Medicaid programs is the adoption of pay-for-performance (P4P) programs, but little evidence exists about the impact of these programs on quality improvement. Our in-depth case investigation of P4P in two safety net settings suggests that such programs may have minimal short-term effect on quality improvement. Two potentially important barriers for P4P in safety net settings are limited motivational effects from financial incentives and complex patient care requirements. We did not uncover any opposition against P4P among providers, nor did we find any evidence that P4P programs may compromise quality of care through unintended consequences. Overall, study results point to opportunities to improve the design and implementation of P4P programs in safety net settings.

Physician attitudes toward pay-for-quality programs: perspectives from the front line.

Pay-for-quality (P4Q) initiatives are becoming an increasingly popular mechanism for improving quality performance and reducing health care costs in the United States. Because these programs often target primary care physicians, it is important to understand how these physicians perceive and respond to P4Q to design successful programs going forward. This study reports results of a survey regarding attitudes toward P4Q among physicians participating in such programs in Massachusetts and California. Findings indicate physicians have generally positive attitudes toward the concept of P4Q, but are ambivalent about certain features of these programs as currently designed and implemented.

Effects of paying physicians based on their relative performance for quality.

BACKGROUND: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. OBJECTIVE: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. PARTICIPANTS: There were 334 participating primary care physicians in Rochester, New York. DESIGN: The design of the study is a retrospective cohort study using pre/post analysis. MEASUREMENTS: The measurements adhere to 4 diabetes performance measures between 1999 and 2004. RESULTS: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. CONCLUSIONS: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

The early experience of a hospital-based pay-for-performance program.

This study evaluated the effect of a health-plan-sponsored, hospital-based financial incentive program, focused on heart-failure quality indicators, to improve quality. We conducted separate, hour-long, semistructured group interviews with senior managers and cardiologists at ten hospitals involved in the Participating Hospital Agreement (PHA) program implemented by Blue Cross Blue Shield of Michigan (BCBSM). Under PHA, hospitals are eligible for an annual incentive payment of up to 4 percent of BCBSM's diagnosis-related-group-based inpatient claims, depending on their performance in patient safety, community outreach, and selected quality indicators. Interviews focused on knowledge, perceptions, and impact of pay-for-performance (P4P) strategies. We compared BCBSM-provided data on heart-failure quality indicators between 2002 and 2004 with our qualitative findings. Our analyses suggest that pursuit of incentive-based quality targets may be largely dependent on the context of a particular hospital. In settings where performance did not change, incentives did not appear to drive organizational or individual practice changes. Underperforming hospitals with some of the infrastructure necessary for quality improvement had the greatest success when presented with incentives. We concluded that one formula for a successful P4P program is to direct incentive payment to an organized entity capable of supporting process improvement by applying resources and organizational expertise. In this model, the incentive program supports the organization, and the organization in turn may apply resources to facilitate improvement in clinician performance. Consideration of the requirements of organizations to facilitate improvement in relation to existing quality improvement infrastructure may lead to the future success of hospital-based P4P programs.

A nucleotide substitution in the tRNA(Lys) primer binding site dramatically increases replication of recombinant simian immunodeficiency virus containing a human immunodeficiency virus type 1 reverse transcriptase.

A recombinant simian immunodeficiency virus (SIV) derived from strain 239 (SIVmac239) with reverse transcriptase (RT) sequences from human immunodeficiency virus type 1 (HIV-1) strain HXB2 was severely impaired for replication. Detectable p27(Gag) levels were not observed until day 65 and peak p27(Gag) levels were not reached until day 75 after transfection of CEMx174 cells with the recombinant DNA. Sequences from the latter time point did not contain amino acid substitutions in HIV-1 RT; however, a single nucleotide substitution (thymine to cytosine) was found at position eight of the SIV primer binding site. We engineered an RT/SHIV genome with the thymine-to-cytosine substitution, called RT/SHIV/TC, and observed dramatically faster replication kinetics than were observed with the parental RT/SHIV from which this variant was derived. RT/SHIV/TC provides an improved system for study of the impact of drug resistance mutations in HIV-1 RT in a relevant animal model.