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Quality or Productivity First? Now We Know

December 17, 2009
by Mark Hagland
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Much has already been written about in what ways, and to what degree, pay-for-performance programs may or may not influence physician behavior. But now comes along a new study from UCLA that has finally dotted the “i’s” and crossed the “t’s” on a key question: should such programs consciously incent quality, or productivity, or both?

Hector P. Rodriguez, an assistant professor in the department of health services at the UCLA School of Public Health and his colleagues found that physicians incented towards improved communication with patients, care coordination, and office-staff interactions, substantially improved their behaviors in the context of the Integrated Healthcare Association’s P4P program. Incentives for addressing the quality of patient-clinician interaction and the overall experience of patient care tended to result in improved performance in those areas, particularly when the incentive funds were used broadly by the physician groups to positively reinforce a patient-centered work culture.

But within those medical groups in which individual physicians were incented towards increased productivity (the IHA allows physician groups considerable leeway in how they internally manage their participation its program), patients actually ended up having a diminished patient experience. The study was a broadly based one, involving 1,444 primary care physicians at 25 California medical groups between 2003 and 2006.

“As the Obama administration and Congress continue to grapple with healthcare reform, these findings provide timely information about the kinds of things medical groups can do—and can avoid doing—with financial incentives in order to improve the quality of patient healthcare experiences,” Rodriguez said in a UCLA press release.

And though it’s important to avoid over-generalizing any kind of study of this type, it would be hard not to see some obvious lessons from this study for clinician incentivization across any patient care setting. As I noted in my September cover story on CPOE, those hospitals and health systems in which CPOE implementation has been most successful have been ones in which clinician and IT leaders have moved forward under the banner of improved patient safety and care quality, not just efficiency.

Of course, P4P is in its infancy relative to its ultimate potential for influencing patient care outcomes and the patient experience. But as more studies like this one emerge, it will be important to keep in mind what kinds of incentives trigger the kinds of clinician behaviors that policymakers, organization leaders, consumers, purchasers and payers, and even clinicians themselves, all say they want to be triggered.

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Comments

Dr. Bankowitz,
You make terrific points. All these terms, including of course quality and efficiency, can be defined and measured in different ways. And while some continue to equate efficiency precisely with productivity or throughput, as you point out, that is not or should not be the equation instead, the elimination of non-value-added activities is a far better definition or element to measure. Thank you for your comments!

Mark,
Thank you for your post. I was not aware of this study and I very much want to reveiw it. I think once again, the Institute of Medicine had it right. If we are going to adress quality in healthcare (through P4P incentive programs or other), it is important to define and measure quality broadly - clinical effectiveness, patient safety, patient centeredness, access to care, equity of care, and yes - efficiency too. I think though that when focusing on efficiency, it is really important to remember the goal is the elimination of waste -or as LEAN students would say - non-value added activities. Seeing more patients, lowering costs and decreasing utilization are not goals in themselves. The real goal is to identify what is waste and then to eliminate it.

Mark Hagland

Editor-In-Chief

Mark Hagland

@hci_markhagland

www.healthcare-informatics.com/blog/mark-hagland

Mark Hagland became Editor-in-Chief of Healthcare Informatics in January 2010. Prior to that, he...