P4P could hurt poor, minorities
While pay-for-performance (P4P) and public quality-reporting programs may contribute to the improvement of healthcare quality, a recent study suggests that such programs might also decrease quality of care for low-income and minority patients.
The study, entitled "Will Pay-For-Performance and Quality Reporting Affect Health Care Disparities," was published on the Web site of the journal Health Affairs.
The authors, Larry Casalino and Arthur Elster, focus primarily on P4P and public reporting programs for physicians, but claim that their findings are applicable to the external incentives aimed at other healthcare providers and institutions.
The authors write that physicians might avoid poor and minority patients if they perceive them to be less likely to have good outcomes from treatment. They also claim that physicians would be more likely to "teach to the test" with poor and minority patients than with affluent and nonminority patients.
According to Casalino and Elster, "teaching to the test" could mean that "with a relatively uneducated diabetic patient who speaks poor English, the physician might focus on making sure the patient has a hemoglobin A1c test (because this is measured) but not on the time-consuming task of explaining to the patient how to control his or her diabetes and blood pressure."
Poor and minority patients might also be less likely to participate in quality improvement initiatives such as disease management programs if they are presented at literacy levels or in cultural styles that the patients find confusing.
Physicians working in areas with high concentrations of poor and minority patients are doubly disadvantaged in trying to achieve high quality scores, the authors write.
First, their "payer mix" is likely to include a high proportion of uninsured and Medicaid patients, so there will likely be less revenue for them to invest in information systems, staff, and the development of organized processes to improve quality. Second, patients in these areas might be less likely to adhere to treatment recommendations.
As a result, people living in poor and minority neighborhoods could end up paying more for medical care as health plans charged higher copays to patients visiting "poor-quality" physicians.
Casalino and Elster offer a number of strategies for the design of quality incentives that will help to reduce disparities in care between disadvantaged and more affluent populations.
These strategies include risk-adjusting quality scores for health status, race and ethnicity, and socioeconomic status; using stratified analysis to compare physicians' performance against that of physicians treating similar patients; and combating "teaching to the test" by rotating quality measures used, adding new measures frequently, and including data from patient satisfaction surveys.
