NEW YORK (Reuters Health) – Pay-for-performance (P4P) programs might improve processes of care in some settings, but they do not consistently improve health outcomes in any setting, according to a systematic review.

“It’s not clear why the evidence has not shown more consistent benefit,” Dr. Devan Kansagara from Oregon Health & Science University and VA Portland Health Care System told Reuters Health by email. “One possibility is that providers are already intrinsically motivated to do the right things for their patients, which makes it harder to show the incremental benefit of a superimposed external incentive.”

P4P programs aim to improve the quality of care, reduce unnecessary use of expensive healthcare services and improve patient health outcomes by providing financial rewards or penalties according to performance on measures of quality.

Dr. Kansagara and colleagues updated and expanded a prior systematic review in order to summarize current understanding of the effects of P4P programs targeting physicians, groups, and institutions on process-of-care and patient outcomes in ambulatory and outpatient settings, both inside and outside the U.S.

They included 69 studies—58 in ambulatory settings and 11 in hospital settings—that examined a wide range of P4P programs with varying incentive structures, goals and contexts. Low-strength evidence suggested that ambulatory P4P programs might improve process-of-care outcomes over the short term, with many of the positive studies conducted in the U.K., where incentives were larger than in the U.S.

The largest process-of-care improvements occurred in areas where baseline performance was poor, the researchers report in Annals of Internal Medicine, online January 10.

P4P programs had no consistent effect on intermediate health outcomes in the ambulatory or hospital setting, although there was low-strength evidence that P4P programs might reduce hospital readmissions.

“I also think the British experience with the Quality and Outcomes Framework program is worth paying attention to,” Dr. Kansagara said. “They have had a longer and more extensive experience with pay for performance than anyone else. While they found some process of care improvements for some incentivized conditions, the overall evidence of benefit with the QOF program has been underwhelming.”

“It is interesting that, after more than a decade of experience, they have decided to scale back the number of metrics in response to provider concerns and the lack of convincing long-term evidence of benefit,” he said.

“I don’t think anyone is arguing that we should return to the days when fee-for-service reimbursement was dominant in health care,” Dr. Kansagara explained. “Value-based purchasing makes intuitive sense and may be an improvement over the historic alternative. They probably should continue to play a role in health reform; we just have to think more carefully about how they are implemented, how many metrics are in place at any given time, and how to minimize negative unintended consequences and the incremental burden placed on providers.”

“P4P is here to stay and, given the lack of clear evidence supporting them, it is all the more important that physicians be active constituents in the development, implementation, and modification of metrics at a local and regional level,” Dr. Kansagara concluded.

Dr. Ricarda Milstein from Universität Hamburg and Hamburg Center for Health Economics in Germany, who reported similar findings in a review of 34 P4P programs in 14 OECD countries, told Reuters Health by email, “This paper confirms the already existing evidence that P4P performs below policy makers’ expectations. This evidence holds true irrespective of the program design and health care system. The lack of response to incentive payments may indicate that physicians are intrinsically rather than extrinsically motivated.”

“I personally am rather relieved by this finding,” she said. “It corrects a negative image of health providers that economists sometimes have – the greedy physician who is only in it for the money, to be blunt. If P4P were found to be more successful, we would see a boom of financial incentives which largely ignore its very worrisome side effects.”

“Policy makers should not make too much of a provider’s reimbursement conditional on P4P,” Dr. Milstein said. “It should be combined with other quality-enhancing policies, such as public reporting. Finally, there should be more analyses on the cost-effectiveness of P4P. I have the feeling that public reporting is just as effective as P4P, but much less costly.”

“Let me also point out that to my understanding, the peak of P4P is over,” she added. “We do see other countries to implement or expand P4P programs, such as Germany and Belgium. This, however, is more to the fact that the U.S. has it and that an OECD country is simply expected to have a P4P program because everyone has one, but not because of the overwhelming, great effect.”