(1). Rosenthal MB and Frank RG. “What is the empirical basis for paying for quality in health care?” Medical Care Research Review, 2006 Apr;63(2):135-57. http://mcr.sagepub.com/cgi/content/abstract/63/2/135.

This study reviewed the existing limited number of evaluations of health care P4P programs, as well non-health research, where there were more studies on pay-for- performance and more widespread acceptance of P4P as an effective way of paying individuals. With regard to health care, the study concluded that “the empirical foundations of pay-for-performance in health care are rather weak. Among the health care studies that we reviewed, many of those with the strongest research designs yielded null results with only two positive findings. On a more positive note, however, it is not clear that the findings from the literature are indeed comparable to the broader efforts now envisioned, which would systematically identify and reward the best providers using multidimensional quality measures.” The study reported mixed findings with regard to the use of P4P outside of the health care setting.
Peer reviewed – meta analysis
Keywords: Evaluation of P4P programs; provider incentives; paying for quality; pay for performance; P4P

(2). Christianson JB, Leatherman S, and Sutherland K. “Lessons from Evaluations of Purchaser Pay-for-Performance: A Review of the Evidence” Medical Care Research and Review, December 2008;65(6) supplement:5S-35S. http://www.ncbi.nlm.nih.gov/pubmed/19015377.

This study considered nine physician programs, of which six focused on diabetes care. Seven offered some type of bonus payments for achieving quality benchmarks, while two returned a percentage of withheld funds. Just one program rewarded both improvement and meeting benchmarks. Most of the evaluation studies used before-after designs with no comparison groups, and in most there was strong potential for “volunteer bias”—potentially leading to false findings of improvement. Nevertheless, these evaluations found significant improvement on at least one quality measure in every program. At least two evaluations were based on a stronger, quasi-experimental evaluation designs: one of these evaluations found improvement in five of six diabetes process measures and two of three diabetes outcome measures. Another found that groups receiving performance payments improved on one process measure (cervical cancer screening), but not on others (provision of mammography and hemoglobin A1c testing).
Peer reviewed – meta analysis
Keywords: Physician quality payments; quality performance payments; quality bonus payments, pay for performance;, P4P

(3). Petersen LA, Woodard LD, Urech T, Daw C and Sookanan S. “Does Pay-for-Performance Improve the Quality of Health Care?” Annals of Internal Medicine, August 15, 2006;145(4):265-272. http://www.annals.org/content/145/4/265.abstract.

This study considered 17 evaluations of physician P4P programs. Nine of these evaluations studied the use of financial incentives directed to provider groups. Of these, seven studies found partial or positive effects on measures of quality (although some of these effects were quite small), and found statistically significant improvements in the measure of quality of care. However, the methodologically strong evaluations, using randomized trials evaluating group-level incentives for preventive health services, found no effect of incentives when compared with the control group. In addition, six studies considered programs that directed incentives to individual physicians (not physician groups). While five of these studies found partial or positive effects, one study showed evidence of a negative effect on access to care for the sickest patients.
Peer reviewed – meta analysis
Keywords: Evaluations of physician P4P programs; physician P4P programs; physician pay for performance; provider financial incentives; randomized trials

(4). Pearson SD, Schneider EC, Kleinman KP, Coltin KL, and Singer JA. “The Impact of Pay-For-Performance on Health Care Quality in Massachusetts, 2001-2003” Health Affairs, July/August 2008;27(4):1167-1176. http://content.healthaffairs.org/cgi/content/abstract/27/4/1167.

This study of P4P programs in Massachusetts examined data from the Massachusetts Health Quality Partners health data organization on the performance of over 5,000 Massachusetts physicians. The researchers considered performance from 2001 to 2003 on thirteen HEDIS measures, comparing physicians practicing under P4P contracts to those not practicing under P4P contracts. The researchers found improved performance on every HEDIS measure among physicians under P4P contracts as well as among physicians not under P4P contracts.
Peer reviewed – individual study
Keywords: pay for performance; P4P; physician P4P programs; Massachusetts

(5). “The California Pay For Performance Program: The Second Chapter Measurement Years 2006 - 2009” Integrated Healthcare Association, June 2009. http://www.iha.org/pdfs_documents/p4p_california/P4PWhitePaper2_June2009_FullReport.pdf.

This is a self-evaluation of the largest P4P initiative in the country involving eight health plans representing 10.5 million insured Californians.[1] The authors reported that participating physician groups improved in all measurement areas, with clinical performance improving by an average of three percentage points annually and patient experience initially by 2.2 percentage points before leveling off. The report concludes that “P4P in California has not yet achieved a primary objective – breakthrough quality improvement.”
Non-peer reviewed study
Keywords: Evaluation of P4P initiatives; Integrated Healthcare Association; pay for performance; P4P; physician P4P programs; California

(6). Lindenauer PK, Remus D, Roman S, Rothberg MB, Benjamin EM, Ma A and Bratzler DW. “Public Reporting and Pay for Performance in Hospital Quality Improvement.” New England Journal of Medicine, February 1, 2007;356(5):486-496. http://content.nejm.org/cgi/content/short/356/5/486.

This methodologically strong study of the Medicare Premier Hospital Quality Initiative found significant improvements attributable to the P4P incentives (2.6 to 4.1 percent) in composite performance over two years. This result was especially notable in that most of the bonus dollars went to hospitals with the highest performance at baseline. The improvement could be explained by the fact that participating hospitals did so voluntarily, were already performing better than average hospitals, were committed to quality improvement activities, and had resources available to support their participation. A further analysis of the results of this study found that the composite scores for each of the five conditions—heart attack (AMI), coronary artery bypass graph (CABG), heart failure, pneumonia, and hip/knee surgery—all improved by seven to 18 percentage points over baseline between years one and three of the study.
Peer reviewed – meta analysis
Keywords: Medicare; Hospital Quality P4P Initiative; hospital pay for performance; P4P; P4P evaluations; incentives

(7). Nahra TA, Reiter KL, Hirth RA, Shermer JE and Wheeler JRC. "Cost-Effectiveness of Hospital Pay for Performance Incentives" Medical Care Research and Review, February 1, 2006;63(1, Suppl.):49S-72S. http://mcr.sagepub.com/cgi/content/abstract/63/1_suppl/49S.

This study evaluated a hospital P4P program sponsored by Blue Cross Blue Shield (BCBS) of Michigan. It found increases in the number of patients receiving reliable care for heart attack (AMI) and congestive heart failure (CHF). Between 2000 and 2003, an increase was found in the percentage of patients receiving the following appropriate processes of care: aspirin after AMI (87 to 95%), beta blocker after AMI (81 to 93%), and angiotensin converting enzyme (ACE) inhibitor after CHF (70 to 80%). In addition to being exposed to the BCBS of Michigan P4P program, these hospitals participated in the CMS pay-for-reporting program, which targeted the same clinical effectiveness measures.
Peer reviewed – individual study
Keywords: Hospital P4P; BCBS of Michigan; P4P; pay for performance; CMS pay-for-reporting

(8). Mehotra A, Damberg CL, Sorbero ME and Teleki SS. “Pay for performance in the hospital setting: what is the state of the evidence?” American Journal of Medical Quality, 2009 Jan-Feb;24(1):19-28. Epub 2008 Dec 10. http://ajm.sagepub.com/cgi/rapidpdf/1062860608326634v1.pdf.

This study evaluated one health plan’s P4P program in Hawaii, implemented for four years. This program made 17 hospitals eligible to receive performance payments based on structure, process, outcome, and patient satisfaction measures. The evaluation used no control group and also had a strong potential for volunteer bias; it found reduced rates of risk-adjusted surgical complications and reduced lengths of stay for several surgical procedures.
Peer reviewed – individual study
Keywords: Hospital P4P; hospital performance payments; hospital pay for performance; P4P

[1] See http://www.iha.org/p4p_california.html.