Pay-for-Performance in Pediatrics: Proceed With Caution

(1)

COMMENTARY

Pay-for-Performance in Pediatrics: Proceed With

Caution

Alyna T. Chien, MD, MSa_{, R. Adams Dudley, MD, MBA}b

a_{Sections of General Pediatrics and Community Health Sciences, Department of Pediatrics, University of Chicago, Chicago, Illinois;}b_{Divisions of Pulmonary and Critical}

Care and Institute for Health Policy Studies, University of California, San Francisco, California

Financial Disclosure: Dr Dudley’s work on this article was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

I

N RESPONSE TOoverwhelming evidence of significant quality problems within adult and pediatric health care, pay-for-performance programs have proliferated rapidly in adult care settings and are beginning to spread into pediatrics.1–6 _{Outpatient pediatric health care is}

be-ing targeted by performance incentives in all 11 of the state Medicaid programs that currently use mance-incentive strategies and 33 of the 93 perfor-mance-incentive programs listed in the Leapfrog Com-pendium (the largest publicly available listing of performance-incentives programs in the country).7,8

We recognize that the current payment system con-tributes to our problems with quality, and we agree with the cautionary tone and measured approach suggested by Profit et al9_{in the May 2007 issue of}_Pediatrics_when

considering whether performance incentives, in the form of pay-for-performance and/or public reporting, should be implemented to promote the quality of care provided by NICUs.

Because these programs require tremendous effort on the part of a wide variety of stakeholders (employers, health plans, health care organizations, and physicians), it is important to consider whether they are worth the effort. Current evidence indicates that performance in-centive strategies may only be modestly effective,10–12_are

not necessarily connected to better outcomes,13,14 _and

can yield undesirable unintended consequences.15–20

We stress 3 general and 2 pediatric-specific issues for those considering the use of this strategy in pediatrics. The purpose of these cautionary points is to make sure that physicians, program designers, and policy makers are aware that there are risks to using performance incentives in health care and that certain performance-incentive tactics developed for adult health care will not translate well to pediatrics.

UNINTENDED CONSEQUENCES OF PERFORMANCE INCENTIVES

Recently, 3 sets of authors systematically reviewed the empirical evidence regarding performance-incentive programs in health care by using similar search and inclusion criteria.10,11,17 _{Although the majority of this}

literature assessed whether performance incentives yield their intended consequences, a small but significant handful of studies also evaluated performance incentives for their unintended effects.

1. Performance incentives can improve documentation without changing underlying quality. Within the small but growing literature on performance incen-tives, 2 studies indicated that performance incentives improve documentation without changing the un-derlying quality of care.21,22

2. Performance incentives can merely reward those al-ready doing well. As part of the evaluation of a pro-totypical performance incentive program imple-mented in California and the Pacific Northwest, 1 study demonstrated that the vast majority of the $3.4 million in financial incentives paid to medical groups went to those who had higher baseline performance and improved the least.20

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

www.pediatrics.org/cgi/doi/10.1542/peds.2007-1158

doi:10.1542/peds.2007-1158 Accepted for publication Apr 27, 2007

Address correspondence to Alyna T. Chien, MD, MS, 5841 S Maryland Avenue, MC 2007, Chicago, IL 60637. E-mail: alyna㛭chien@yahoo.com

186 CHIEN, DUDLEY

at Viet Nam:AAP Sponsored on August 29, 2020

www.aappublications.org/news

(2)

3. Performance incentives can alter how willing physi-cians and/or health care organizations are to care for minorities and the medically complicated. An evalu-ation of the coronary artery bypass graft report-card effort in New York State found that black and His-panic patients received coronary artery bypass grafts less often than their white counterparts after public reporting began.19 _{Additionally, a study of patients}

being treated for substance abuse in Maine showed that patients with the most severe substance abuse problems were less likely to be treated after Maine’s Office of Substance Abuse introduced financial incen-tives for improving abstinence, increasing employabil-ity, and reducing family and legal problems.18

ISSUES SPECIFIC TO PEDIATRICS

The performance incentive programs that are proliferat-ing in adult health care emphasize rewardproliferat-ing disease-specific processes of health care that are connected to

better outcomes (eg, ␤blockers after acute myocardial

infarction). Program designers have focused on evi-dence-based disease-specific processes of care for com-mon adult conditions because providers presumably control these processes better than health care outcomes (which depend on numerous factors outside a provider’s control, such as patient preference and adherence).23–26

This general strategy faces critical challenges in pediatrics for 2 basic reasons:

1. The low prevalence of disease in pediatrics enlarges the sample-size problem in performance-incentive programs. Limited sample sizes at the provider level are already an issue for programs that target common

adult conditions.15 _{This problem would be}

dramati-cally magnified in pediatrics. Children with condi-tion-specific health care needs are a fraction of the total child population that is already one quarter that

of the adult population.27_{Those who implement}

pe-diatric-focused incentive strategies will need to pay even greater attention to methods of aggregating measures across conditions or to developing perfor-mance measures that reflect more general processes of health care (eg, measures that reflect patient-cen-teredness or care coordination).

2. The paucity of evidence-based quality-of-care metrics poses a greater risk of setting standards of care that are not connected to outcomes. It also increases the reliance on consensus-driven guidelines and poses a greater risk of setting standards that are not objec-tive.28–30_{Pediatric strategies will need to exert an even}

greater effort to make sure that goals are meaningful, realistic, and achievable by providers working in a wide range of settings. Special care should be taken to include solo and/or small group providers and those who work in less-resourced rural or urban settings.

Given the recent explosion of interest in the use of performance incentives and the substantial evidence that quality is poor under the current payment system, it is reasonable to consider whether this strategy will be helpful for improving the quality of pediatric health care. The inherent risks and challenges, which are enhanced in pediatrics, make it important to think carefully about alternatives to existing performance strategies. Re-searchers, physicians, and policy makers must think cre-atively about interventions that foster providers’ natural sense of altruism. Developing methods that support in-trinsic motivation may prove to be more fruitful than performance incentives in guaranteeing long-term and

sustainable improvements to our health care system.31

REFERENCES

1. Mitka M. Report cites shortcomings in quality of pediatric health care.JAMA.2004;291:2688 –2689

2. Leatherman SM, McCarthy D.Quality of Health Care for Children and Adolescents: A Chartbook. New York, NY: Commonwealth Fund; 2004. Available at: www.cmwf.org/usr㛭doc/ leatherman㛭pedchartbook㛭700.pdf. Accessed April 15, 2007 3. McGlynn EA, Asch SM, Adams J, et al. The quality of health

care delivered to adults in the United States. N Engl J Med.

2003;348:2635–2645

4. Rosenthal MB, Landon BE, Normand SLT, Frank RG, Epstein AM. Pay for performance in commercial HMOs.N Engl J Med.

2006;355:1895–1902

5. Centers for Medicaid and Medicare Services. Pay-for-perfor-mance initiatives: Herb Kuhn testimony for the Senate Com-mittee on Finance. Available at: www.cms.hhs.gov/apps/ media/press/testimony.asp?Counter⫽1537. Accessed November 23, 2005

6. Centers for Medicaid and Medicare Services. Medicare pay-for-performance demonstration shows significant quality of care improvement at participating hospitals. Available at: www. cms.hhs.gov/apps/media/press/release.asp?Counter⫽1441. Ac-cessed November 23, 2005

7. Centers for Medicaid and Medicare Services, Center for Health Care Strategies. Descriptions of selective performance incentive programs. Available at: www.cms.hhs.gov/smdl/downloads/ StatePerformanceIncentiveChart040606.pdf. Accessed No-vember 23, 2005

8. Leapfrog Group. The Leapfrog compendium. Available at: http://ir.leapfroggroup.org/compendium. Accessed March 31, 2007

9. Profit J, Zupancic JAF, Gould JB, Petersen LA. Implementing pay-for-performance in the neonatal intensive care unit. Pedi-atrics.2007;119:975–982

10. Dudley RA, Frolich A, Robinowitz DL, Talavera JA, Broadhead P, Luft HS. Strategies to support quality-based purchasing: a review of the evidence. Available at: www.ahrq.gov/clinic/tp/ qpurchtp.htm. Accessed May 3, 2007

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

12. Lindenauer PK, Remus D, Roman S, et al. Public reporting and pay for performance in hospital quality improvement.N Engl J Med.2007;356:486 – 496

13. Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for pa-tients hospitalized with heart failure.JAMA.2007;297:61–70 14. Werner RM, Bradlow ET. Relationship between Medicare’s

PEDIATRICS Volume 120, Number 1, July 2007 187

(3)

hospital compare performance measures and mortality rates [published correction appears inJAMA. 2007;297:700].JAMA.

2006;296:2694 –2702

15. Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual physician “report cards” for assessing the costs and quality of care of a chronic disease.JAMA.1999;281:2098 –2105

16. Chien AT, Chin MH, Davis AM, Casalino LP. Pay-for-perfor-mance, public reporting and racial disparities in health care: how are programs being designed?Med Care Res Rev.2007; In press 17. Chien AT. The potential impact of performance incentive

pro-grams on racial disparities in health care. In: Williams RA, ed.

Eliminating Healthcare Disparities in America: Beyond the IOM Report.Totowa, NJ: Humana Press; In press

18. Shen Y. Selection incentives in a performance-based contract-ing system.Health Serv Res.2003;38:535–552

19. Werner RM, Asch DA, Polsky D. Racial profiling: the unin-tended consequences of coronary artery bypass graft report cards.Circulation.2005;111:1257–1263

20. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA.

2005;294:1788 –1793

21. Fairbrother G, Hanson KL, Friedman S, Butts GC. The impact of physician bonuses, enhanced fees, and feedback on child-hood immunization coverage rates.Am J Public Health.1999; 89:171–175

22. Kouides RW, Bennett NM, Lewis B, Cappuccio JD, Barker WH, LaForce FM. Performance-based physician reimbursement and influenza immunization rates in the elderly. The Primary-Care Physicians of Monroe County.Am J Prev Med.1998;14:89 –95

23. American Medical Association. Guidelines for the develop-ment of pay-for-performance programs. Available at: www. ama-assn.org/ama1/pub/upload/mm/368/guidelines4pay62705. pdf. Accessed May 10, 2007

24. American Medical Association. Principles for Pay-for-Performance. Available at: www.ama-assn.org/ama1/pub/upload/mm/368/ principles4pay62705.pdf. Accessed May 3, 2007

25. Dudley RA, Frolich A, Robinowitz DL, Talavera JA, Broadhead P, Luft HS.Pay for Performance: A Decision Guide for Purchasers. Rockville, MD: Agency for Healthcare Research and Quality; 2006. AHRQ publication 06-0047

26. American College of Physicians. Linking physician payments to quality care. Available at: www.acponline.org/hpp/link㛭pay. pdf. Accessed September 7, 2006

27. Dovey S, Weitzman M, Fryer G, et al. The ecology of medical care for children in the United States. Pediatrics. 2003;111: 1024 –1029

28. Kaplan SH, Greenfield S, Connolly GA, Barlow SE, Grand R. Methodologic issues in the conduct and interpretation of pe-diatric effectiveness research.Ambul Pediatr.2001;1:63–70 29. Christakis DA, Johnston BD, Connell FA. Methodologic

is-sues in pediatric outcomes research.Ambul Pediatr.2001;1: 59 – 62

30. Schuster MM, McGlynn EA. Measuring the Quality of Care in Pediatrics. Philadelphia, PA: Lippincott, Williams and Wilkins; 1999

31. Frølich A, Talavera JA, Broadhead P, Dudley RA. A behavioral model of clinician responses to incentives to improve quality.

Health Policy.2007;80:179 –193

188 CHIEN, DUDLEY

(4)

DOI: 10.1542/peds.2007-1158

2007;120;186

Pediatrics

Alyna T. Chien and R. Adams Dudley

Pay-for-Performance in Pediatrics: Proceed With Caution

Services

Updated Information &

http://pediatrics.aappublications.org/content/120/1/186

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/120/1/186#BIBL

This article cites 18 articles, 3 of which you can access for free at:

Subspecialty Collections

sub

http://www.aappublications.org/cgi/collection/quality_improvement_

Quality Improvement

_management_sub

http://www.aappublications.org/cgi/collection/administration:practice

Administration/Practice Management

following collection(s):

This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

in its entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

(5)

DOI: 10.1542/peds.2007-1158

2007;120;186

Pediatrics

Alyna T. Chien and R. Adams Dudley

Pay-for-Performance in Pediatrics: Proceed With Caution

http://pediatrics.aappublications.org/content/120/1/186

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2007 has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it