P4P may 'divert' healthcare from those who need it the most
Pay-for-performance programs could increase medical disparities experienced by racial and ethnic minorities and people of low socioeconomic status, according to a new RAND Corporation study.
In a typical pay-for-performance program, researchers found, medical practices that serve vulnerable populations would likely receive lower payments than other practices, a result of existing gaps in the quality of healthcare received by patients in these groups.
The study, which was published in Health Affairs, is the first to simulate the impact of pay-for-performance on physician practices that serve medically vulnerable communities.
In 2007 the Centers for Medicare and Medicaid Services established a three-year pay-for-performance demonstration with physicians to promote the adoption and use of health information technology to improve the quality of patient care for chronically ill Medicare patients. Participating practices are rewarded for reporting clinical quality data and meeting clinical performance standards for treating diabetes, congestive heart failure and coronary artery disease. They are also measured and rewarded for how well they provide preventive services (immunizations, blood pressure screening and cancer screening) to high-risk, chronically ill Medicare beneficiaries. The demonstration is ongoing in California, Arkansas, Massachusetts and Utah and will continue through June 30.
The study simulated how a pay-for-performance plan used in a Medicare demonstration project would affect primary care physician group practices in Massachusetts that treated patients enrolled in any of the commonwealth's five largest commercial health plans. A total of 438 primary care practices and their patients were included in the study, which used performance information from 2007.
Researchers in the study found that average-sized physician practices serving the highest proportion of vulnerable populations would receive about $7,100 less annually than other practices. That difference could be even larger if greater amounts of money are put at stake in future pay-for-performance programs, researchers said.
A report published in the Annals of Internal Medicine says healthcare providers who are monitored by such limited criteria (provided by P4P programs) have a powerful incentive to dismiss or refuse to accept patients whose outcome measures fall below the quality standard and therefore worsen the provider's assessment. Patients with low health literacy or inadequate financial resources to afford expensive medications or treatments and ethnic groups traditionally subject to healthcare inequities may also be "deselected" by providers seeking improved performance measures, according to a report published in the Yale Journal of Health Policy Law Ethics.
"Paying for performance may have the unintended effect of diverting medical resources away from the communities that need these resources the most," said Mark Friedberg, the study's lead author and an associate natural scientist at RAND, a nonprofit research organization. "If you don't watch where the money goes, pay-for-performance programs have the potential to make disparities worse."
According to researchers, few physicians and other medical providers are located in communities with large, medically vulnerable populations. If they receive lower reimbursements than other providers, new resources may be diverted elsewhere, making it difficult to reverse existing disparities.
Study findings suggest that pay-for-performance programs need to be structured to account for the payment shortfalls that could worsen medical disparities. One approach could be to provide targeted grants to physicians for caring for vulnerable populations, which could offset resource disparities while preserving the incentive to improve care for these populations.
"We found that practices that treat vulnerable populations have room for performance improvement, so it's important to preserve the incentive to improve quality of care while taking steps to prevent an increase in disparities," Friedberg said.
In a second study that was also published in Health Affairs, RAND researchers conclude that the best way to strengthen primary care in the United States is to reorient the focus of the health system rather than training more primary care providers.
"There is limited evidence that simply increasing the number of primary care physicians in the nation will improve health and slow the growth of healthcare costs unless we also reorient the system to focus on primary care," said Eric Schneider, a senior natural scientist at RAND and an author of the study.
According to the study, health systems should encourage patients to use primary care providers as coordinators of their healthcare, shift investment from high-technology services to support community-based primary care and improve communication between specialists and primary care providers.
