Over the last decade, pay for performance (P4P) programs have been implemented in a variety of health systems, including the VHA, as a means to improve the efficiency and quality of health care. There has been a parallel increase in the number of studies examining the effects of P4P. A number of recent reviews have summarized this literature, but have generally found insufficient evidence to broadly characterize the balance of harms and benefits. However, financial incentives programs are complex interventions whose effects may depend in part on the settings in which they are implemented, the methods used for implementation, the populations targeted, and the characteristics of the incentive programs themselves.

The objectives of this report are to summarize the positive and negative effects of P4P on process and health outcomes, and to examine how implementation characteristics modify the effects of P4P programs. The Key Questions used to guide our report are:

Key Question 1: What are the effects of pay for performance programs on patient outcomes and processes of care?

Key Question 2: What implementation factors modify the effectiveness of pay for performance?

Key Question 3: What are the positive and negative unintended consequences, including any effect on health disparities, associated with pay for performance?

Contents

• PREFACE
• ACKNOWLEDGMENTS
• EXECUTIVE SUMMARY
  • INTRODUCTION
  • METHODS
  • RESULTS
  • DISCUSSION
• BACKGROUND
• CONCEPTUAL FRAMEWORK
• METHODS
  • TOPIC DEVELOPMENT
  • SEARCH STRATEGY
  • STUDY SELECTION
  • DATA ABSTRACTION
  • QUALITY ASSESSMENT
  • DATA SYNTHESIS AND ANALYSIS
  • SUMMARY OF RAND'S FINDINGS ON PAY FOR PERFORMANCE PROGRAMS
  • DISCUSSIONS WITH KEY INFORMANTS
• RESULTS
  • LITERATURE FLOW
  • KEY QUESTION 1 What are the effects of pay for performance on patient outcomes and processes of care?
  • KEY QUESTION 2 What are the implementation factors that modify the effectiveness of pay for performance?
  • KEY QUESTION 3 What are the positive and negative unintended consequences, including any effect on health disparities, associated with pay for performance?
• SUMMARY AND DISCUSSION
  • SUMMARY OF EVIDENCE BY KEY QUESTION
  • DISCUSSION
• REFERENCES
• APPENDIX A TECHNICAL EXPERT PANEL
• APPENDIX B PICOTS TABLE
• APPENDIX C SEARCH STRATEGIES
• APPENDIX D INCLUSION AND EXCLUSION CRITERIA
• APPENDIX E STUDIES SUMMARIZED IN DAMBERG, 2014
• APPENDIX F KEY INFORMANT DISCUSSION GUIDE, TEMPLATE
• APPENDIX G KEY INFORMANTS
• APPENDIX H PEER REVIEW COMMENTS AND RESPONSES

Prepared for: Department of Veterans Affairs, Veterans Health Administration, Quality Enhancement Research Initiative, Health Services Research & Development Service, Washington, DC 20420. Prepared by: Portland Evidence-based Synthesis Program (ESP) Center, Portland VA Medical Center, Portland, OR, Devan Kansagara, MD, MCR, Director

Suggested citation:

Kondo K, Damberg C, Mendelson A, Motu'apuaka M, Freeman M, O'Neil M, Relevo R, Kansagara D. Understanding the intervention and implementation factors associated with benefits and harms of pay for performance programs in healthcare. VA-ESP Project #05-225; 2015.

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the VA Portland Health Care System, Portland, OR, funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.