gms | German Medical Science

Background: “Pay-for-performance (P4P) programs are designed to offer financial incentives to meet defined quality, efficiency, or other targets”.

The objective was to evaluate the effectiveness of P4P and to identify barriers and facilitators for the effectiveness.

Material and methods: A systematic literature search was performed in several economic and medical databases (06/2016). Manual searches were performed. Cluster randomized controlled trials, controlled before after studies (CBAs), and interrupted time series (ITS), comparing P4P to a payment scheme without a component that incentivises quality, were included. The primary outcome was quality of care. Data were extracted in a-priori piloted standardized tables. Risk of bias (RoB) was assessed with the EPOC-Cochrane tool. If necessary the data were reanalysed.

Study selection, data extraction and RoB assessment were performed by two reviewers independently. Discrepancies were discussed until consensus.

A structured data synthesis was performed. Data from subgroup analyses and evaluation of difference between P4P-programms were used to analyse the influencing factors.

Results: Four ITS and 11 CBAs on six different P4P programs (four in the USA, two UK [England , NHS]) as add-on to DRG based payments were identified. RoB was high. The main reason in CBAs was the difference in baseline measures between intervention and control hospitals and the risk of contamination. The main reason in ITS was the unclear effect of time trends.

All studies showed a slight effect in favour of P4P. Effect of result indicators (e.g. mortality) was mostly low and decreased in the long-term. Strong short term effects were most clear for penalties. Effects were larger using higher incentives and in hospitals in a good financial situation. The influence of the baseline quality of hospitals was heterogeneous. An effect was observed in programs that pay for quality targets but not in programs that pay for quality improvement.

Effects were lower if other quality interventions were already implemented (e.g. public reporting), in more competitive markets, and in voluntary programs.

Conclusion: The effect of P4P seems to be modest. The level of incentive and the financial situation of hospitals seem to have influence on the effect. The interactions between P4P-design (e.g. low incentives) and (interacting) context factors (e.g. competition) seems to be particular important. The results are limited by the low level of evidence.