Cost Control Incentives Don't Affect Patient Outcomes When Quality Variables are Implemented

Among physicians and hospital administrators, the phrase "pay for performance," or P4P, is often heard as the government and health insurers increasingly try to tie reimbursement for services to how well doctors and hospitals control their costs.

However, until now its been uncertain whether pay-for-performance programs actually lead to better or worse patient care. But a new four-year study out of Continuum Health Partners, a consortium of hospitals in New York City, has found that pay-for-performance programs can help cut costs without affecting patient care when quality variables are implemented. The researchers presented their findings at the 2011 annual Clinical Congress of the American College of Surgeons.

The researchers mined databases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and the Society of Thoracic Surgeons to investigate eight different types of major operations, from gastric bypass to lung procedures, performed at three New York City hospitals from 2007 through 2010, a total of 1,768 patient cases. The investigators found that complications and death rates did not change appreciably after pay-for-performance programs were initiated, reported lead investigator Faiz Y. Bhora, MD, MBBS, FACS, associate program director, general surgery program, St. Lukes-Roosevelt Hospital Center. He said this is one of the first studies of pay for performance that has looked at patient outcomes.

Bhora said his research team advocates that quality care outcomes should be the essential framework for pay-for-performance programs. He explains they came to their conclusions mostly by analyzing measures used from ACS NSQIP, the first nationally validated program to measure outcomes and improve the quality of surgical care. ACS NSQIP collects data on 136 variables, including risk factors before surgery, variables during surgery, and survival and morbidity outcomes for up to 30 days after surgery. The complications compiled by the NSQIP database and used in the New York analysis include pneumonia, pulmonary embolism, unplanned breathing tube insertion, acute renal failure, bleeding requiring transfusion, cardiac arrest, coma, stroke, and superficial surgical site infection and wound disruption within 30 days.

What pay-for-performance programs are trying to do is align the goals of the physician and the institutions so that they work as a symbiotic unit, with a decrease in the tremendous amount of entrenched, superfluous expenditures and inefficiencies, Bhora says. Our presumption was there should be no difference in the outcomes or quality. Theres always a concern that incentive programs may affect the quality of care.

The operations the researchers looked at besides gastric bypass were colorectal operations, removal of the appendix and gall bladder, bypass of occluded arteries, carotid artery endarterectomy, and complete and partial removal of the lung. We found no significant difference before and after implementation of pay for performance in studying the overall outcomes for these procedures, Bhora says.

For example, in 269 colorectal operations observed, the complication rate went from 30 percent before pay for performance to 22 percent afterward. For lung operations, the complication rates increased slightly while death rates declined slightly. None of the variations in outcomes before and after pay for performance were statistically significant, according to Bhora and his team.

With pay-for-performance programs, there is also concern that physicians will avoid sicker, frailer patients in order to make their outcomes look better, but Bhora said this study found no evidence of that. Our case mix index was no different before or after pay for performance; there was no evidence of cherry picking of cases, he said.

The pay-for-performance program at the New York hospitals involved gainsharing, where participating physicians share in a percentage of the cost savings the institution realizes, along with a host of quality measures that physicians must meet in order to participate. Those measures included timely dictation of medical records and appropriate use of blood-pressure lowering drugs and antibiotics, among other quality care strategies.

The quality issue is something that I and my research team feel very passionately about, Bhora says. With limited resources, it is very important for our national health care system to have synergy of goals between physicians and institutions so that the inefficiencies that exist within the health care system are reduced. The cornerstone of any pay-for-performance program has to be the continued delivery of excellent and quality care. Thats where we as physicians need to stay engaged with pay-for-performance programs, so that its not just a financial program, but a quality program as well.

The study was led by Syed Shahzad Razi, MD. In addition to Dr. Bhora, other investigators included Koji Park, MD; Ruth Levin, MA; Robert Catalano, MD; Claudie Jimenez, MD; Jordan Sasson, MD; Scott Belsley, MD, FACS; and George Todd, MD, FACS.