Thank you for joining us today!

1. Thank you for joining us today! Please dial 1.800.732.6179 now to connect to the audio for this webinar. To show/hide the control panel click the double arrows.

2. Presentation by Christopher Millett and Brian Hutchison Wednesday, September 23, 2009

3. What is pay for performance?

4. What is pay for performance? • Providing financial incentives to health plans or providers for meeting performance targets set by payers – i.e. insurers, government

5. P4P programs vary considerably • Bonus, penalty, auto-assignment • Reward achievement or improvement • Size of incentive (2–30% of income) • Quality measures used • Process or outcome • Preventative, CDM • Risk adjustment

6. Comprehensive P4P in the U.K.Quality and Outcomes Framework (QOF) • 25% of practice income from a complex set of incentives • 3 domains; chronic disease management, practice organization, patient experience • 1050 points (1 point = CA$220) • 550 clinical domain points • 356 points = CVD + diabetes

7. Diabetes QOF (18 indicators) DM 2 The percentage of patients with diabetes whose notes record BMI in the previous 15 months (3 points – threshold 40-90%) DM 8 The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months (5 points – threshold 40-90%) DM 6 The percentage of patients with diabetes in whom the last HbA1C is 7.4 or less in last 15 months (17 points – threshold 40-50%)

8. Selective P4P - the Ontario example Focused on activities (outputs) rather than quality (processes) of care Output incentives primarily address access concerns P4P incentives are available to physicians participating in patient enrollment models Mix of incentives varies across payment models

9. Process of care incentives Graduated bonuses for achieving target levels of provision of preventive services to enrolled patients: Pap smears Mammograms Influenza vaccination Childhood immunization Colorectal cancer screening

10. Examples of output incentives Payments for providing priority services above threshold levels (e.g., obstetrical deliveries, palliative care, minor surgery, home visits, hospital care, and care of patients with chronic mental illness) Fees for contacting patients to schedule appointments for screening and prevention Fees for enrolling unattached patients Fee for completion of diabetic care flow sheet Premiums for after-hours care Add-on smoking cessation counseling fee

11. What is the evidence that pay for performance has worked?

12. What is the evidence that pay for performance has worked? • Evidence remains limited Christianson JB. Med Care Res Rev. 2008 Petersen LA. Ann Intern Med. 2006 • Difficult to disentangle P4P from other quality initiatives and secular trends • Evaluation of U.K. scheme ongoing

14. Are there unintended consequences?

15. 1. Potential adverse impact on disparities Millett C. Diabetes Care 2009

16. 2. Exclusion of sicker patients California P4P (McDonald, Annals Family Medicine 2009) “I told someone, you’re killing my pay for performance. Go join another medical group” U.K. P4P Exception reporting Older patients, women, those with comorbidity more likely to be excluded (Simpson, BMC Fam Prac. 2007)

17. 3. Neglect of non-incentivized care? • Aspects of care that were not incentivized in the U.K. P4P declined for patients with asthma or heart disease between 2005 and 2007 Campbell et al. N Engl J Med. 2009

18. 4. Undermining intrinsic motivation? For complex tasks, extrinsic incentives tend to reduce intrinsic motivation and performance unless they are consonant with personal and professional interests, values and sense of self Deci et al.Psych Bulletin 1999 Gagné and Deci. J Org Behavior 2005

19. What are the prerequisites for implementation?

20. What are the prerequisites for implementation? • Money • Professional involvement and sign-up • High penetration of HIT • Patient enrolment (to establish denominators)

21. Does it deliver value for money?

22. Does it deliver value for money? • Difficult to evaluate as “savings” derived from improved quality take time to accrue • Bigger picture in U.K.: - Importance of investing in primary care • Unanswered research question: Does P4P produce incremental benefits in the presence of ongoing performance feedback and quality improvement support?

23. How to ask a question… • To ask your question verbally, please enter *1 on your telephone. • To submit your question in writing please use the “Questions” box on the control panel.

24. Thank you! For more information on this or future sessions please visit www.chsrf.ca/researcheroncall