NHS Study: P4P Doesn't Improve Care

Early trials of systems that award bonus payments to physicians who adopt quality-enhancing, health-improving practices have shown promise, and the possibility of including such systems in health reform legislation has been there since it began snowing last winter.

But to the chagrin of many, a study published in last week’s New England Journal of Medicine suggests that P4P doesn’t always work.

Stephen Campbell and colleagues at the University of Manchester conducted a time-series analysis of the quality of care at 42 family practices in England.

Focusing on the management of asthma, diabetes and coronary heart disease, they assessed care practices twice before a pay for performance scheme went into effect (1998 and 2003) and twice more after it was implemented (2005 and 2007).

With respect to the behaviors specifically addressed by the P4P program, the scientists found that between 2003 and 2005, the rate of improvement in the quality of care increased for asthma and diabetes but not for coronary disease. By 2007, the rate of improvement had plateaued for all 3 conditions.

The scientists also found that some behaviors not covered by the P4P program actually worsened during the trial period. In particular, a measure of the continuity of care declined shortly after the P4P scheme began, and remained at the lower level for the rest of the trial period.

"This could be an unintended and perverse effect of the scheme and is a concern, since continuity is an aspect of family practice that patients value," they wrote.

They attributed the decline to practices devoting excessive resources towards a particular incentive that rewarded practices in which patients were seen by a physician within 48 hours of their initial request.

The researchers hypothesized that the declining rates with which quality improved during the P4P program might have been caused by the failure of the program to reward gains beyond a certain level, or that "family practitioners had sufficient income and had little personal motivation to improve performance and income further.”

Glenn Laffel, MD, PhD, Sr. VP, Clinical Affairs