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Background: Unplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk., Methods: In 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the "G78717" fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all nonelective hospitalizations potentially eligible for the incentive over a 5-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients., Results: A total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95% CI, 0.93-1.01; P = .23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95% CI, 0.95-1.05; P = .93)., Conclusions: A physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere., Trial Registration: ClinicalTrials.gov ID, NCT03256734., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To understand the effect of physician payment incentives on the allocation of health care resources., Data Sources/study Setting: Review and analysis of the literature on physician payment incentives., Study Design: Analysis of current physician payment incentives and several ways to modify those incentives to encourage increased efficiency., Principal Findings: Fee-for-service payments can be incorporated into systems that encourage efficient pricing - prices that are close to the provider's marginal cost - by giving consumers information on provider-specific prices and a strong incentive to choose lower cost providers. However, efficient pricing of services ultimately will need to be supplemented by incentives for efficient production of health and functional status., Conclusions: The problem with current FFS payment is not paying a fee for each service, per se, but the way in which the fees are determined., (© Health Research and Educational Trust.)

Objective: To test the effectiveness of physician incentives for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins., Data Sources: Pharmacy and medical claims from a large Medicare Advantage Prescription Drug Plan from January 2011 to December 2012., Study Design: We conducted a randomized experiment (911 primary care practices and 8,935 nonadherent patients) to test the effect of paying physicians for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins. We measured patients' medication adherence for 18 (6) months before (after) the intervention., Data Collection/extraction Methods: We obtained data directly from the health insurer., Principal Findings: We found no evidence that physician incentives increased adherence in any drug class. Our results rule out increases in the proportion of days covered by medication larger than 4.2 percentage points., Conclusions: Physician incentives of $50 per patient per drug class are not effective for increasing patient medication adherence among the drug classes and primary care practices studied. Such incentives may be more likely to improve measures under physicians' direct control rather than those that predominantly reflect patient behaviors. Additional research is warranted to disentangle whether physician effort is not responsive to these types of incentives, or medication adherence is not responsive to physician effort. Our results suggest that significant changes in the incentive amount or program design may be necessary to produce responses from physicians or patients., (© Health Research and Educational Trust.)

Objectives: To assess quality, cost, physician productivity, and patient experience for 2 primary care physician (PCP) practice styles: the focused, who typically address only the patient's acute problem, versus the max-packers, who typically address additional conditions also., Study Design: Retrospective observational study using administrative data, electronic health record (EHR) data, and patient surveys. Data represent 285 PCPs (779 PCP-years) in a large, multispecialty group practice during 2011, 2012, and 2013., Methods: PCPs were ranked each year by their number of additional conditions addressed during acute care visits. The top one-third (max-packers) addressed 25.4% more "other problems" than expected, while focused PCPs (bottom one-third) addressed 20.3% fewer than expected. Outcomes were resource use, clinical quality metrics, patient-reported experience, physician time using the EHR, and physician productivity. All measures were risk-adjusted to account for patient mix. T tests were used to compare measures., Results: Relative to a focused pattern of care, max-packing was associated with 3.4% lower overall resource use, consistently better scores for the available clinical quality metrics, and comparable patient experience (except for worse wait time ratings). Patients of focused PCPs used 7.3% more specialist services, in terms of costs, than patients of max-packers ($1218 vs $1136; P <.001). Max-packers spent 40 minutes more per clinical day using the EHR. PCPs with less appointment availability and who used a mix of appointment slots were more likely to be max-packers., Conclusions: Max-packing behavior yields desirable outcomes at lower overall cost but involves more conventionally uncompensated PCP time. Alternatives to compensation just for face-to-face visits and using more flexible scheduling may be needed to support max-packing.

Background: Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive., Aims: To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis., Method: Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening., Results: Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37-20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33-10.10)., Conclusions: The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.

Objective: To identify the facilitators and barriers to implement family doctor contracting services in China by using Consolidated Framework for Implementation Research (CFIR) to shed new light on establishing family doctor systems in developing countries., Design: A qualitative study conducted from June to August 2017 using semistructured interview guides for focus group discussions (FGDs) and individual interviews. CFIR was used to guide data coding, data analysis and reporting of findings., Setting: 19 primary health institutions in nine provinces purposively selected from the eastern, middle and western areas of China., Participants: From the nine sampled provinces in China, 62 policy makers from health related departments at the province, city and county/district levels participated in 9 FGDs; 19 leaders of primary health institutions participated in individual interviews; and 48 family doctor team members participated in 15 FGDs., Results: Based on CFIR constructs, notable facilitators included national reform involving both top-down and bottom-up policy making (Intervention); support from essential public health funds, fiscal subsidies and health insurance (Outer setting); extra performance-based payments for family doctor teams based on evaluation (Inner setting); and positive engagement of health administrators (Process). Notable barriers included a lack of essential matching mechanisms at national level (Intervention); distrust in the quality of primary care, a lack of government subsidies and health insurance reimbursement and performance ceiling policy (Outer setting); the low competency of family doctors and weak influence of evaluations on performance-based salary (Inner setting); and misunderstandings about family doctor contracting services (Process)., Conclusions: The national design with essential features including financing, incentive mechanisms and multidepartment cooperation, was vital for implementing family doctor contracting services in China. More attention should be paid to the quality of primary care and competency of family doctors. All stakeholders must be informed, be involved and participate before and during the process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown., Aim: To identify and quantify unintended consequences associated with the DES18 and DIS schemes., Design and Setting: A retrospective cohort quantitative study of 7079 English primary care practices., Method: Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics., Results: National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators., Conclusion: The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience., (© British Journal of General Practice 2019.)

Background: Collaboration between graduate medical education (GME) and health systems is essential for the success of patient safety initiatives. One example is the development of an incentive program aligning trainee performance with health system quality and safety priorities., Objective: We aimed to improve trainee safety event reporting and engagement in patient safety through a GME incentive program., Methods: The incentive program was implemented to provide financial incentives to drive behavior and engage residents and fellows in safety efforts. Safety event reporting was measured beginning in the 2014-2015 academic year. A training module was introduced and the system reporting link was added to the institution's Resident Management System homepage. The number of reports by trainees was tracked over time, with a target of 2 reports per trainee per year., Results: Baseline data for the year prior to implementation of the incentive program showed less than 0.5% (74 of 16 498) of safety reports were submitted by trainees, in contrast with 1288 reports (7% of institutional reports) by trainees in 2014-2015 ( P < .0001). A total of 516 trainees (57%), from 37 programs, received payment for the metric, based on a predefined program target of a mean of 2 reports per trainee. In 2015-2016 and 2016-2017 the submission rate was sustained, with 1234 and 1350 reports submitted by trainees, respectively., Conclusions: An incentive program as part of a larger effort to address safety events is feasible and resulted in increased reporting by trainees., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Recent changes in the health care delivery landscape have expanded opportunities for clinical pharmacists in the ambulatory care setting. This article describes the successful integration of a clinical pharmacist-led chronic disease management service in a patient-centered medical home (PCMH) and accountable care organization (ACO) environment., Program Description: In 2008, the year before PCMH implementation, 36% of patients who were hospitalized at Advocate Trinity Hospital for a heart failure exacerbation were readmitted within 30 days of their hospital stay for heart failure exacerbation. This high rate of heart failure hospital readmissions, compared with national standards, drove the implementation of the PCMH at Advocate Medical Group - Southeast Center (AMG-SE), the adjoining outpatient medical clinic. A clinical pharmacist was added to the health care team to help achieve the collective goal of improving patient outcomes and decreasing hospitalizations., Observations: From November 1, 2009, through August 30, 2010, the clinical pharmacist conducted visits and intervened in the care of 111 chronic heart failure patients. A pre/post analysis of those 111 patients during the 10 months before and after the integration of the clinical pharmacist showed that those patients were hospitalized 63 times in the 10 months before having regularly scheduled visits with the clinical pharmacist and 30 times in the 10 months after establishing care. This reduction from 63 to 30 visits translated to an approximate 50% decrease in heart failure hospitalizations in patients being followed by the clinical pharmacist within the first 10 months. Once the clinical pharmacist became better integrated into the workflow through development of rapport with the medical team, the outcomes improved further. In an 18-month analysis from May 1, 2010, through November 30, 2011, only 2% of patients (3 of 153) designated as high-risk patients managed by the clinical pharmacist had a 30-day readmission for heart failure exacerbation., Implications: Outcomes-based models have expanded opportunities for clinical pharmacist involvement and can provide unique reimbursement options. Demonstration of cost savings and an improvement in quality measures are paramount to establishing and justifying the clinical pharmacist's role in a team-based model of care., Disclosures: No outside funding supported this research. The authors have no conflicts of interest to disclose.

Blended capitation physician payment models incorporating fee-for-service (FFS), pay-for-performance and/or other payment elements seek to avoid the extremes of both FFS and capitation. However, evidence is limited regarding physicians' responses to blended models, and potential shifts in service provision across payment categories within the practice. We examine the switch from FFS to a blended capitation-FFS model for primary care physicians in group practice. The empirical analysis shows patients experiencing 9-14% reductions in capitated services and simultaneous increases of 10-22% in FFS services from their rostering physicians. Unusually, our data permit changes among non-rostering physicians to be observed. Other physicians within the rostering group reduce the provision of capitated fee codes, with no net change in FFS services. All other physicians in the jurisdiction reduce both capitated and FFS services, which is consistent with patients concentrating their primary care with one provider as a result of capitation., (Copyright © 2018. Published by Elsevier B.V.)

Study Objective: We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts., Methods: An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality., Results: Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%., Conclusion: The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

As healthcare continues to consume more and more of provincial government spending, there is a continuing pressure to improve efficiency and cut overall costs. In this increasingly constrained healthcare system, value for money is a growing focus of discussions around accountability and system sustainability; healthcare leaders are required to find ways of measuring, enforcing, and reporting on that value. In 2014, our organization began implementing an innovative system of structured incentives, linking distribution of Ministry of Health and Long-Term Care academic physician funding to quality and performance goals. Through a carefully planned process of benchmarking, stakeholder consultation, model improvement, and change management, we were able to move to a new value for money allocation model. The new model drives accountability by linking distribution of government payments to quality and performance outcomes. Initial results include increased stakeholder satisfaction as well as broader physician engagement in corporate and academic quality improvement initiatives.

Incentive-based pay is rational, intuitive, and popular. Agency theory tells us that a principal seeking to align its incentives with an agent's should be able to simply pay the agent to achieve the principal's desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States' behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care's recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising. But there is a problem: mixed preliminary evidence and potential mal-effects on vulnerable third-party patients. This Article employs a new lens-the legal and behavioral literature on optimal contract specificity-to suggest why incentive pay is problematic and why the health-care experience will be no different than other industries. The use of incentive pay is a change in contractdrafting strategy, a decision to write a more detailed, control-based contract rather than one that relies on discretion. The contracts literature suggests that this strategy will only work well where simple compliance is the goal rather than creativity or innovation. The health industry will not succeed in implementing incentive pay better than other industries have. What it needs is to recognize the limits of incentive pay and implement it sparingly. The new Trump Administration may be particularly primed to heed this call.

Background: An opportunity to address the needs of patients with common mental disorders (CMDs) resides in primary care. Barriers are restricting availability of treatment for CMDs in primary care. By understanding the incentives that promote and the disincentives that deter treatment for CMDs in a collaborative primary care context, this study aims to help contribute to goals of greater access to mental healthcare., Method: A qualitative pilot study using semi-structured interviews with thematic analysis., Results: Participants identified 10 themes of incentives and disincentives influencing quality treatment of CMDs in a collaborative primary care setting: high service demands, clinical presentation, patient-centred care, patient attributes, education, physician attributes, organizational, access to mental health resources, psychiatry and physician payment model., Conclusion: An understanding of the incentives and disincentives influencing care is essential to achieve greater integration and capacity for care for the treatment of CMDs in primary care., (Copyright © 2016 Longwoods Publishing.)

Background: In primary care, financial incentives have usually been directed to physicians because they are thought to make the key decisions in order to change the functions of a medical organization. There are no studies regarding the impact that directing these incentives to all disciplines of the care team (e.g. group bonuses for both nurses and doctors) may have, despite the low frequency with which diagnoses were being recorded for primary care visits to doctors. This study tested the effect of offering group bonuses to the care teams., Methods: This was a retrospective quasi-experimental study with before-and-after settings and two control groups. In the intervention group, the mean percentage of visits to a doctor for which a diagnosis was recorded by each individual care team (mean team-based percentage of monthly visits to a doctor with recorded diagnoses) and simultaneously the same data was gathered from two different primary care settings where no team bonuses were applied. To study the sustainability of changes obtained with the group bonuses the respective data were derived from the electronic health record system for 2 years after the cessation of the intervention. The differences in the rate of marking diagnoses was analyzed with ANOVA and RM-ANOVA with appropriate post hoc tests, and the differences in the rate of change in marking diagnoses was analyzed with linear regression followed by t-test., Results: The proportion of doctor visits having recorded diagnoses in the teams was about 55 % before starting to use group bonuses and 90 % after this intervention. There was no such increase in control units. The effect of the intervention weakened slightly after cessation of the group bonuses., Conclusion: Group bonuses may provide a method to alter clinical practices in primary care. However, sustainability of these interventions may diminish after ceasing this type of financial incentive.

Background: Management of operating room inventory has substantial cost-saving opportunities if surgeons agree to standardize supplies used to perform procedures; however, there is no incentive for surgeons to participate in these decisions, because the cost-savings are realized only by the hospital, not the practitioner. In an attempt to engage surgeons with the management of the operating room supply chain, a shared-savings programs was instituted that returned 50% of money saved to the surgery divisions., Methods: Opportunities for savings in the use of biologic mesh, cranial plating systems, and neurostimulators was identified. Each item was assigned a physician champion responsible for ensuring that there was clinical equipoise between the products being used. Any cost-savings realized during the fiscal year were shared 50-50 between the hospital and the surgery divisions., Results: The total cost-savings was $893,865 with $446,932 being shared across 15 surgery divisions. Standardization of cranial plating systems ($374,805) generated the greatest amounts of savings followed by neurostimulators ($278,404) and biologic mesh ($240,655)., Conclusion: Aligning hospital and surgeon incentives led to dramatic cost-savings and standardization of the operative inventory used. Quality of care is not compromised by this approach, and no conflicts of interest are created., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State., Design: Practice-level, randomized prospective evaluation., Setting: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan)., Participants: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices)., Intervention: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. After each chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care., Main Outcome Measures: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis)., Results: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization for children in treatment relative to control practices., Conclusions: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years., (© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Objective: To evaluate the effects of Quality and Outcomes Framework (QOF) incentivised case finding for depression on diagnosis and treatment in targeted and non-targeted long-term conditions., Design: Interrupted time series analysis., Setting: General practices in Leeds, UK., Participants: 65 (58%) of 112 general practices shared data on 37,229 patients with diabetes and coronary heart disease targeted by case finding incentives, and 101,008 patients with four other long-term conditions not targeted (hypertension, epilepsy, chronic obstructive pulmonary disease and asthma)., Intervention: Incentivised case finding for depression using two standard screening questions., Main Outcome Measures: Clinical codes indicating new depression-related diagnoses and new prescriptions of antidepressants. We extracted routinely recorded data from February 2002 through April 2012. The number of new diagnoses and prescriptions for those on registers was modelled with a binomial regression, which provided the strength of associations between time periods and their rates., Results: New diagnoses of depression increased from 21 to 94/100,000 per month in targeted patients between the periods 2002-2004 and 2007-2011 (OR 2.09; 1.92 to 2.27). The rate increased from 27 to 77/100,000 per month in non-targeted patients (OR 1.53; 1.46 to 1.62). The slopes in prescribing for both groups flattened to zero immediately after QOF was introduced but before incentivised case finding (p<0.01 for both). Antidepressant prescribing in targeted patients returned to the pre-QOF secular upward trend (Wald test for equivalence of slope, z=0.73, p=0.47); the slope was less steep for non-targeted patients (z=-4.14, p<0.01)., Conclusions: Incentivised case finding increased new depression-related diagnoses. The establishment of QOF disrupted rising trends in new prescriptions of antidepressants, which resumed following the introduction of incentivised case finding. Prescribing trends are of concern given that they may include people with mild-to-moderate depression unlikely to respond to such treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Faculty awards provide an incentive to encourage higher standards of personal performance, which closely reflects the quality of health care. We report the development and implementation of the first medical faculty award program in the region., Material and Methods: Anonymous preaward survey evaluated responses to understand the overall state of our institution. Five awards were celebrated. An anonymous postaward survey gathered responses to evaluate the effectiveness of the program., Results: A total of 60% (307/509) of preaward survey responses were collected. Among those, 92% (283/307) felt that employee recognition was important and 78% (240/307) felt that performance should be the deciding criteria for employee recognition. A 24% (20/85) of the faculty received the decade of excellence award and 13% (11/85) received the compassionate physician award. Best service award was granted to 7% (6/85) of the nominees. Postaward survey showed 68% (170/250) agreed that the award ceremony incentivized them to increase quality of personal performance., Conclusion: In summary, we feel that this transparent, objective, and peer-nominated awards program could serve as an incentivized model for health care providers to elevate the standards of personal performance, which in turn will benefit the advancement of patient care.

When assessing a pay-for-performance arrangement, the following factors should be considered: Existence and/or size of minimum savings threshold before savings are allocated. Savings allocation percentage available to physicians. Benchmarks used to measure quality against past performance and/or medical evidence. Ways in which quality outcomes are measured and paid for. Per member per month payments for patient management. Physician investment (participation fee, time, or capital). Existence of downside risk to physicians. Employed compensation structure (if applicable).

Objectives: To estimate: (1) the percentage of physicians whose compensation is variable; (2) the frequency at which performance incentives for productivity, care quality, patient satisfaction, and resource use were used to determine compensation; and (3) how much incentives differ for physicians who serve greater percentages of patients who are Medicaid-insured, racial/ethnic minorities, or who face language barriers, versus those who do not., Study Design: Cross-sectional study of 3234 nationally representative physicians responding to the 2008 Center for Studying Health System Change's Health Tracking Physician Survey (HTPS)., Methods: We examined the degree to which practices' percentage of Medicaid revenues and physicians' panel characteristics were associated with physicians' financial incentives using χ² statistics and multivariate logistic regression (adjusting for physician specialty, practice type, and capitation levels, and area-based factors)., Results: Compensation was variable for 69% of respondents, was most frequently tied to productivity (68%), and less often to care quality (19%), patient satisfaction (21%), or resource use (14%). Physicians were significantly less likely to report variable compensation if the percentage Medicaid revenues was 50% or more (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI], 0.57-0.95) or if physician panels were at least 50% Hispanic (adjusted OR 0.74, 95% CI, 0.56-0.99). However, physicians were significantly more likely to report use of all 4 performance incentives if percentage of Medicaid revenues was 6% to 24%., Conclusions: Physicians report different types of financial incentives designed to alter care quality and quantity; incentive types differ by the degree that practices derive revenues from Medicaid or serve Hispanic patients. Further investigation is needed to understand how to align financial incentives with disparity-reduction efforts.

In the last decade, there has been a rapidly growing emphasis and imperative for healthcare quality improvement. With the vast number of stakeholders involved, it is reaching a pinnacle of activity and requirements. The federal government has been developing and implementing quality initiatives across the healthcare system spectrum. This article looks at three major programs: the Hospital Value-based Purchasing/Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting, and the Physician Quality Reporting System /Physician Value-based Payment Modifier. Quality measurement in healthcare will continue to grow and evolve. Current and upcoming programs will expand, change, and likely disappear or morph into variations of themselves.

This study investigates heterogeneity in Thai doctors' job preferences at the beginning of their career, with a view to inform the design of effective policies to retain them in rural areas. A discrete choice experiment was designed and administered to 198 young doctors. We analysed the data using several specifications of a random parameter model to account for various sources of preference heterogeneity. By modelling preference heterogeneity, we showed how sensitivity to different incentives varied in different sections of the population. In particular, doctors from rural backgrounds were more sensitive than others to a 45% salary increase and having a post near their home province, but they were less sensitive to a reduction in the number of on-call nights. On the basis of the model results, the effects of two types of interventions were simulated: introducing various incentives and modifying the population structure. The results of the simulations provide multiple elements for consideration for policy-makers interested in designing effective interventions. They also underline the interest of modelling preference heterogeneity carefully., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objective: To develop quality prescribing indicators for general practitioners (GPs) who are non-monitored and not included in pay-for-performance programs, and to determine compliance with incentivized and non-incentivized indicators., Study Design: Descriptive cross sectional study., Setting: Aljarafe Primary Health Care Area (Andalusian Public Health Care Service, Spain), a rural and suburban area with a population of 323,857 inhabitants. Health assistance in this area is provided by 176 GPs in 37 health centers. Prescribing indicators were developed by a multidisciplinary group using a qualitative technique based on consensus. The members of the consensus group searched for updated recommendations focused on clinical evidence. Prescribing data were obtained from the computerised pharmacy records of reimbursed drugs and clinical data from the electronic clinical databases and hospital admission records., Results: Fourteen indicators based on the selection of drugs of different therapeutic groups or linked to patient´s clinical information were designed. The compliance with indicators based on the selection of drugs linked to financial incentives was higher than that of indicators not linked to financial incentives. The compliance with indicators based on clinical information varied widely. Inappropriate prescribing ranged from 7 %, in the use of long-acting beta-agonists in asthma, to 86 % in the use of drugs for the prevention of osteoporotic fractures in young women., Conclusions: This study shows better compliance by GPs with indirect and incentivized quality prescribing indicators, included in pay-for-performance programs, compared with not-incentivized indicators based on the relative use of drugs and on the appropriateness prescribing.

Background: The current economic environment makes it difficult for academic institutions to maintain academic activities with necessary clinical coverage. Productivity-based faculty compensation is reported to improve clinical work output; however, the impact on academic productivity has not been fully described., Methods: An academic anaesthesiology department has used a comprehensive clinical and academic performance-based faculty compensation programme as fiscal year (FY) 2004. Faculty choosing to pursue an academic track can devote up to 80% of their time to non-clinical activities. Payment for this time is 'salary at risk', which is earned through a merit matrix system, which was newly developed to award points for various academic activities. Unclaimed portions of the salary at risk are absorbed into the department budget at the conclusion of the FY. Clinical activities are measured chiefly based on total hours of anaesthetic care., Results: Academic full-time equivalents (FTEs) decreased by 12.0% in FY2005 (FTE of 16.0-14.1) but recovered to the baseline level in FY2006 and remained stable. Clinical FTE also decreased by 6.6% in FY2005 (FTE of 109.1-101.9), then increased in FY2006-FY2010. Increased clinical work output was observed among the clinical and academic faculty members. Each academic faculty member successfully earned their salary at risk in each FY. The annual number of peer-reviewed publications per academic FTE in original research increased from 0.31 (0.18) (FY2001-FY2003) to 0.73 (0.14) (FY2006-FY2011), P=0.024., Conclusions: Integration of clinical and academic performance-based faculty compensation systems is feasible and can be efficacious in a large academic anaesthesiology department.

Background: Patient care revenue is becoming an increasingly important source of funding to support the academic surgery department missions of research and education. Transparency regarding productivity metrics will improve clinical productivity among members of an academic surgical practice., Study Design: Clinical productivity-related data were collected and compared between 2 time periods. Data were stratified by pretransparency and post-transparency time periods. Comparisons were made using the Wilcoxon-Mann-Whitney test, and p values ≤0.05 were considered significant., Results: The faculty compensation plan remained the same across both time periods; faculty members were paid a base salary plus practice plan income based on individual collections minus practice overhead and academic program support taxes. Before 2006, clinical productivity data were not made public among faculty members. In 2006, the departmental leadership developed a physician scorecard that led to transparency with regard to productivity. After publication of the scorecard, clinical productivity increased, as did the number of partners producing a threshold number of work relative value units (RVU) (6,415 wRVU = 1.0 full time equivalent [FTE]). This occurred during a time of reduced collections per RVU. There was no change in the work assignments (percent effort for clinical service, research, and teaching) for the physicians between the 2 time periods, or the overall effort assigned to the Veterans Affairs hospital., Conclusions: Clinical productivity can be improved by making productivity metrics transparent among faculty members. Additional measures must be taken to ensure that research and teaching activities are appropriately incentivized., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF)., Aim: To obtain a longer term perspective on the implementation of the QOF., Design and Setting: Qualitative study with 47 health professionals in 23 practices across England. Method Semi-structured interviews., Results: Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients' best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences., Conclusion: Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care.

Background: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects., Objective: To assess changes in performance after introducing a participatory P4P program., Design: An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark., Main Outcome Measures: Quality indicators for clinical care (process and outcome) and patient experience., Results: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement., Conclusions: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

Introduction: Despite the widespread use of physician return-for-service (RFS) programs in Canada, few have been evaluated. We examined two types of RFS agreements (Family Medicine Bursary and Special Funded Residency Position) and (a) describe the proportion of RFS physicians who complete their service obligation and identify the predictors of completion and (b) compare the retention of RFS physicians to that of non-RFS physicians., Methods: Using administrative data on physicians with RFS agreements in Newfoundland and Labrador (NL), Memorial University's Postgraduate Medical Education Office and the Physician and Medical Practice Database, we calculated the proportion of RFS physicians (1997-2009) who fulfilled their service obligation and also identified predictors of completion. We then followed to 2010 a cohort of physicians who started practice in NL between 2000 and 2005 to compare the retention of RFS and non-RFS physicians., Results: Ninety-six (71.6%) of 134 RFS physicians fulfilled the service obligation in full. Physicians who held Special Funding Residency Position RFS agreements were 11.1 times less likely (95% CI: 4.0-33.3) to complete their service commitment than physicians who held Family Medicine Bursary RFS agreements. In the cohort of 60 RFS and 67 non-RFS physicians, 16.9% of RFS versus 41.8% of non-RFS physicians left NL by 2010 (p=0.004). RFS physicians were 3.22 times less likely (95% CI: 1.41-7.14) than non-RFS physicians to leave the province. Four years after starting practice, roughly 90% of RFS versus 60% of non-RFS physicians remained in NL; after 10 years, 70% of RFS versus 60% of non-RFS physicians remained (p=0.006)., Conclusion: The RFS program improves the retention of physicians in NL. Using RFS tied to bursaries rather than residency positions may increase service completion and retention rates., (Copyright © 2013 Longwoods Publishing.)

Poor motivation of providers, primarily caused by low remuneration and/or non-existence of financial incentives, has been a key challenge to improve the quality of maternal health services in the public sector health facilities in rural Bangladesh. An operations research study examined the impact of performance-based incentive for service providers at the institutional level to improve the quality of maternal health services. Quality of care was assessed through monitoring visits of professionals from higher-level health facilities, which contributed to improved service provision within the facilities. Quality scores of the facilities increased from 55% to 78% in 14 months of intervention with significant improvement in antenatal care, postnatal counseling, and institutional delivery (p < 0.01). Importantly, client satisfaction increased remarkably in the intervention facilities. Performance-based incentive has the potential for motivating service providers in improving the quality of maternal health services and for increasing the utilization of facilities for maternal health services in Bangladesh.

Cigna's Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans. Registered nurses who serve as care coordinators employed by participating practices are a central feature of the initiative. They use patient-specific reports and practice performance reports provided by Cigna to improve care coordination, identify and close care gaps, and address other opportunities for quality improvement. We report interim quality and cost results for three geographically and structurally diverse provider practices in Arizona, New Hampshire, and Texas. Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care, suggesting that a shared-savings accountable care model and collaborative support from the payer can enable practices to take meaningful steps toward full accountability for care quality and efficiency.

Managers and policymakers are seeking practical guidelines for assessing the outcomes of emerging pay-for-performance (P4P) programs. Evaluations of P4P programs published to date are mixed-some are confusing-and methodological problems with them are common. This article first identifies and summarizes obstacles to implementing effective P4P programs. Second, it describes results from social science research going back several decades to support evidence-based P4P best practices. Among the findings from this research, the zero-sum and "earn it back" P4P incentive systems have important drawbacks and may be counterproductive, neither reducing health system costs nor improving quality. The research suggests that punishing participants for low performance may further reduce individuals' performance, especially when involvement is required. We suggest that optimal P4P systems are those that reward all participants for performance improvements. Third, the article links P4P design to budgetary considerations. P4P program designs that provide incentives while improving quality and reducing costs are critical if budget neutrality is a priority for the organization and its resources are limited. In these types of P4P designs, cost calculations are straightforward: The greater the participation, the higher the savings. The article concludes by recommending an evidence-based P4P approach for practitioners that can be implemented without large upfront investment. More research on this topic is also advised.

This article provides an overview of the national initiatives developed for monitoring and reporting quality performance measures. Included is a review of the Physician Quality Reporting System, the Hospital Outpatient Quality Data Reporting Program, and the Hospital Outpatient Prospective Payment System, with specific emphasis on how these programs affect radiology practice. A practical review of these programs allows radiologists to gain further understanding of the economic and political influences on the daily practice of radiology today. The background and relevant features of each program are presented in this article., (Copyright © 2012 Elsevier Inc. All rights reserved.)