P4P Schemes Research Articles

Effects of Payment for Performance on accountability mechanisms: Evidence from Pwani, Tanzania

Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountability mechanisms. We examined the effect of P4P in Tanzania on internal and external accountability mechanisms. We carried out 93 individual in-depth interviews, 9 group interviews and 19 Focus Group Discussions in five intervention districts in three rounds of data collection between 2011 and 2013. We carried out surveys in 150 health facilities across Pwani region and four control districts, and interviewed 200 health workers, before the scheme was introduced and 13 months later. We examined the effects of P4P on internal accountability mechanisms including management changes, supervision, and priority setting, and external accountability mechanisms including provider responsiveness to patients, and engagement with Health Facility Governing Committees. P4P had some positive effects on internal accountability, with increased timeliness of supervision and the provision of feedback during supervision, but a lack of effect on supervision intensity. P4P reduced the interruption of service delivery due to broken equipment as well as drug stock-outs due to increased financial autonomy and responsiveness from managers. Management practices became less hierarchical, with less emphasis on bureaucratic procedures. Effects on external accountability were mixed, health workers treated pregnant women more kindly, but outreach activities did not increase. Facilities were more likely to have committees but their role was largely limited. P4P resulted in improvements in internal accountability measures through improved relations and communication between stakeholders that were incentivised at different levels of the system and enhanced provider autonomy over funds. P4P had more limited effects on external accountability, though attitudes towards patients appeared to improve, community engagement through health facility governing committees remained limited. Implementers should examine the lines of accountability when setting incentives and deciding who to incentivise in P4P schemes.

Understanding causal pathways within health systems policy evaluation through mediation analysis: an application to payment for performance (P4P) in Tanzania

BackgroundThe evaluation of payment for performance (P4P) programmes has focused mainly on understanding contributions to health service coverage, without unpacking causal mechanisms. The overall aim of the paper is to test the causal pathways through which P4P schemes may (or may not) influence maternal care outcomes.MethodsWe used data from an evaluation of a P4P programme in Tanzania. Data were collected from a sample of 3000 women who delivered in the 12 months prior to interview and 200 health workers at 150 health facilities from seven intervention and four comparison districts in Tanzania in January 2012 and in February 2013. We applied causal mediation analysis using a linear structural equation model to identify direct and indirect effects of P4P on institutional delivery rates and on the uptake of two doses of an antimalarial drug during pregnancy. We first ran a series of linear difference-in-difference regression models to test the effect of P4P on potential mediators, which we then included in a linear difference-in-difference model evaluating the impact of P4P on the outcome. We tested the robustness of our results to unmeasured confounding using semi-parametric methods.ResultsP4P reduced the probability of women paying for delivery care (−4.5 percentage points) which mediates the total effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 78%). P4P reduced the stock-out rate for some essential drugs, specifically oxytocin (−36 percentage points), which mediated the total effect of P4P on institutional deliveries (by 22%) and deliveries in a public health facility (by 30%). P4P increased kindness at delivery (5 percentage points), which mediated the effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 49%). P4P increased the likelihood of supervision visits taking place within the last 90 days (18 percentage points), which mediated 15% of the total P4P effect on the uptake of two antimalarial doses during antenatal care (IPT2). Kindness during deliveries and the probability of paying out of pocket for delivery care were the mediators most robust to unmeasured confounding.ConclusionsThe effect of P4P on institutional deliveries is mediated by financing and human resources factors, while uptake of antimalarials in pregnancy is mediated by governance factors. Further research is required to explore additional and more complex causal pathways.

Is the distribution of care quality provided under pay-for-performance equitable? Evidence from the Advancing Quality programme in England.

BackgroundThe limited number of existing previous studies of the distribution of quality under NHS Pay-for-performance (P4P) by income deprivation have not analysed the relationship at the individual level and have been restricted to assessing P4P in the primary care setting. In this study, we set out to examine how achievement of P4P 'quality measures' for which NHS hospitals were paid was distributed by income deprivation.MethodsDesign: Retrospective analysis of performance data reported by hospitals, examining how the probability of receiving 23 indicators varied by patients’ area deprivation using logistic regression controlling for age and gender. Sample: We use anonymised observational data on 73,002 patients admitted to hospitals in the North West of England between October 2008 and March 2010 for the following five reasons: acute myocardial infarction; coronary artery bypass grafting; heart failure; hip and knee replacement; and pneumonia.ResultsThe relationship between quality and deprivation varies depending on the point of delivery in the treatment pathway, and on whether delivered for conditions in scheduled or unscheduled care. For diagnostic tests on arrival, receipt of quality was: pro-rich in scheduled care and pro-poor in unscheduled care. Receipt of quality was pro-poor for pre-surgery measures in scheduled care. Receipt of quality at discharge was pro-rich.ConclusionUnlike in primary care, in secondary care quality is not systemically distributed by income deprivation under P4P. Whilst improvements in health inequalities are important system objectives; they may not necessarily be achieved by the adoption of P4P schemes in hospitals.

The effectiveness of payment for performance in health care: A meta-analysis and exploration of variation in outcomes

BackgroundPay for performance (P4P) incentive schemes are increasingly used world-wide to improve health system performance but results of evaluations vary considerably. A systematic analysis of this variation in the effects of P4P schemes is needed. MethodsEvaluations of P4P schemes from any country were identified by searching for and updating systematic reviews of P4P schemes in health care in four bibliographic databases. Outcomes using different measures of effect were converted into standardized effect sizes (standardized mean difference, SMD) and each study was categorized as to whether or not it found a positive effect. Subgroup analysis, meta-regression and multilevel logistic regression were used to investigate factors explaining heterogeneity. Random-effects models were used because they take into account heterogeneity likely to be due to differences between studies rather than just chance. Sensitivity analysis was used to test the effect of different assumptions. Findings96 primary studies were identified; 37 were included in the meta-analysis and meta-regression and all 96 in the logistic regression. The proportion of observed variation in study results that can be explained by true heterogeneity (I2) was 99.9%. Estimates of effect of P4P schemes were lower in evaluations using randomized controlled trials (SMD=0.08; 95% CI: 0.01–0.15) compared to no controls (0.15; 95% CI: 0.09–0.21), and lower for those measuring outcomes (e.g., smoking cessation) (SMD=0.0; 95% CI: −0.01 to 0.01) compared to process measures (e.g., giving cessation advice) (0.18; 95% CI: 0.06–0.31).Adjusting for other design features and the evaluation method, the odds of showing a positive effect was three times higher for schemes with larger incentives (>5% of salary/usual budget) (OR=3.38; 95% CI: 1.07–10.64). There were non-statistically significant increases in the odds of success if the incentive is paid to individuals (as opposed to groups) (OR=2.0; 95% CI: 0.62–6.56) and if there is a lower perceived risk of not earning the incentive (OR=2.9; 95% CI: 0.78–10.83). Schemes evaluated using less rigorous designs were 24 times more likely to have positive estimates of effect than those using randomized controlled trials (OR=24; 95% CI: 6.3–92.8). InterpretationEstimates of the effectiveness of incentive schemes on health outcomes are probably inflated due to poorly designed evaluations and a focus on process measures rather than health outcomes. Larger incentives and reducing the perceived risk of non-payment may increase the effect of these schemes on provider behavior.

Incentives in Rheumatology: the Potential Contribution of Physician Responses to Financial Incentives, Public Reporting, and Treatment Guidelines to Health Care Sustainability.

Concerns about the sustainability of current health care expenditure are focusing attention on the cost, quality and value of health care provision. Financial incentives, for example pay-for-performance (P4P), seek to reward quality and value in health care provision. There has long been an expectation that P4P schemes are coming to rheumatology. We review the available evidence about the use of incentives in this setting and provide two emerging examples of P4P schemes which may shape the future of service provision in rheumatology. Currently, there is limited and equivocal evidence in rheumatology about the impact of incentive schemes. However, reporting variation in the quality and provision of rheumatology services has highlighted examples of inefficiencies in the delivery of care. If financial incentives can improve the delivery of timely and appropriate care for rheumatology patients, then they may have an important role to play in the sustainability of health care provision.

PMD82 - 3-D PRINTING IS REVOLUTIONIZING THE MEDICAL DEVICES WORLD, BUT ARE PAYERS READY?

3D printed medical devices have the potential for significant innovation and clinical advantages in addressing unmet needs, such as the ability to create customized implants fit-for- purpose tailored to meet patient’s individual anatomy. In this research, we explore the challenges in reimbursing 3D printed devices and what manufacturers can do to address them. We have undertaken desk research and 10 telephone interviews with payers, surgeons, and industry experts in the US and several European markets (France, Germany, Belgium, Sweden, Spain, and Switzerland) in late 2014 and early 2015. 3-D printing is not on payers’ radar yet, as it is mostly reimbursed via DRG. 3-D printed medical devices with a higher price premium vs. conventional devices will face a higher degree of scrutiny, as budget impact and safety profile (in light of frequent medical device safety scandals) are primary payer concerns. Where cost is less of an issue, on a hospital-level the “hassle factor,” financial incentives, and P4P schemes may significantly affect the uptake of 3D printed medical devices for the mainstream patient. Market access success of 3D printed devices will depend on balance between consolidated surgeon workload (pre and during surgery) and safety aspects of the device (wear and tear). The commercial problem is the current lack of regulations for in-hospital printed devices, which threatens the 3D industry and the patient (as quality control cannot be on same level as industrial-made). Payer interests will depend on pricing vs. not 3D printed devices (from no interest if within same DRG, to high interest if with additional budget, or need for higher DRG). The key point is to find out cost effectiveness (or efficiency) of 3D printed medical devices versus standard devices, e.g., impact on direct medical cost, and length of surgery.

A Doctor’s Worth

Pay-for-performance (P4P) programs, based on productivity, patient satisfaction, quality of care, efficiency profiling, or unspecified criteria have become popular in American medicine. Theoretically, such programs hold the potential to narrow the gender pay gap among physicians by employing what are arguably neutral, meritocratic criteria. Such criteria are often unspecified in prior analyses but in reality may include a host of indicators, including objective features of performance, dimensions that entail a high degree of discretion, and gendered aspects, such as masculine competence (i.e., intelligence, confidence, efficiency, and decisiveness) or feminine warmth (i.e., kindness, trustworthiness, sympathy, and selflessness). Using data from four waves of the Community Tracking Study (CTS) Physician Surveys, I analyze the effects of such unique P4P criteria on the gender pay gaps among physicians. Most notable among findings is more pronounced gender inequality when criteria are unspecified as opposed to being based on productivity. No effect is found when P4P centers on warmer patient satisfaction criteria. I conclude by discussing how and why P4P schemes may reduce but also exacerbate gender inequalities in pay.

Financial incentive schemes in primary care.

Pay-for-performance (P4P) schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals’ behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost–benefit emerges.

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study.

BackgroundDespite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania.MethodsWe evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed.FindingsWe estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid.ConclusionThis study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.

Pay-for-performance in health care services: a review of the best evidence available

Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.

The use of outcome and process indicators to incentivize integrated care for frail older people: a case study of primary care services in Sweden.

A number of reforms have been implemented in Swedish health care to support integrated care for frail older people and to reduce utilization of hospital care by this group. Outcomes and process indicators have been used in pay-for-performance (P4P) schemes by both national and local governments to support developments. To analyse limitations in the use of outcome and process indicators to incentivize integrated care for elderly patients with significant health care needs in the context of primary care. Data were collected from the Region Skåne county council. Eight primary care providers and associated community services were compared in a ranking exercise based on information from interviews and registered data. Registered data from 150 primary care providers were analysed in regression models. Both the ranking exercise and regression models revealed important problems related to risk-adjustment, attribution, randomness and measurement fixation when using indicators in P4P schemes and for external accountability purposes. Instead of using indicators in incentive schemes targeting individual providers, indicators may be used for diagnostic purposes and to support development of new knowledge, targeting local systems that move beyond organizational boundaries.

Impacts of pay for performance on the quality of primary care.

Increasingly, financial incentives are being used in health care as a result of increasing demand for health care coupled with fiscal pressures. Financial incentive schemes are one approach by which the system may incentivize providers of health care to improve productivity and/or adapt to better quality provision. Pay for performance (P4P) is an example of a financial incentive which seeks to link providers’ payments to some measure of performance. This paper provides a discussion of the theoretical underpinnings of P4P, gives an overview of the health P4P evidence base, and provide a detailed case study of a particularly large scheme from the English National Health Service. Lessons are then drawn from the evidence base. Overall, we find that the evidence for the effectiveness of P4P for improving quality of care in primary care is mixed. This is to some extent due to the fact that the P4P schemes used in primary care are also mixed. There are many different schemes that incentivize different aspects of care in different ways and in different settings, making evaluation problematic. The Quality and Outcomes Framework in the United Kingdom is the largest example of P4P in primary care. Evidence suggests incentivized quality initially improved following the introduction of the Quality and Outcomes Framework, but this was short-lived. If P4P in primary care is to have a long-term future, the question about scheme effectiveness (perhaps incorporating the identification and assessment of potential risk factors) needs to be answered robustly. This would require that new schemes be designed from the onset to support their evaluation: control and treatment groups, coupled with before and after data.

Paying for improvements in quality: recent experience in the NHS in England

There is a long-term international trend towards linking payments more closely to providers’ performance. The US and England have been at the forefront of the design and introduction of such pay-for-performance (P4P) schemes. England’s experience is, however, likely to have greater salience for the Nordic countries’ health care systems due to the publicly funded finance structure. We review the development of five of England’s major schemes and summarise the available evidence on their impacts. These schemes are: the Quality and Outcomes Framework (QOF); Advancing Quality; the Commissioning for Quality and Innovation (CQUIN) framework; Best Practice Tariffs; and the newest ‘non-payment’ policies. Much of the evidence is limited by the non-experimental way in which the schemes have been introduced, with limited data available prior to the introduction of the schemes and no experimentally unexposed providers to serve as controls. Nonetheless, the existing evidence suggests that P4P can result in modest short-term improvements in the incentivised aspects of performance. There is little evidence of effort diversion, yet some to suggest positive spillovers of these schemes onto non-incentivised aspects of performance. While there is some evidence of gaming and inequitable consequences, these do not appear to be widespread. The gains that can accrue across large patient populations as a result of relatively small financial incentives mean that P4P schemes can be cost-effective. P4P programmes are likely to be most effective when introduced as a supporting part to a wider quality improvement initiative, and when results are published to encourage a reputational as well as a financial incentive for improvement. Though the accumulation of evidence to support P4P has not been systematic or especially robust, it remains a popular policy tool with decision-makers in England, with its reach set to increase further in the future.

Information Asymmetry and Hybrid Advertising

Pay-for-performance (P4P) pricing schemes such as pay-per-click and pay-per-action have grown in popularity in Internet advertising. Meanwhile, the traditional pay-per-impression (PPI) scheme persists, and several advertising publishers have started to offer a hybrid mix of PPI and P4P schemes. Given the proliferation of pricing scheme choices, our study examines the optimal choices for advertising publishers. We highlight two-sided information asymmetries in online advertising markets and the consequent tradeoffs faced by a high-quality publisher using P4P schemes. When there exists information asymmetry, P4P pricing schemes enable a high-quality publisher to reveal her superior quality; on the other hand, they may incur allocative inefficiencies stemming from inaccurate estimates of advertiser qualities. Our study identifies conditions under which a publisher may opt for a PPI, P4P, or a hybrid scheme and in doing so provides a theoretical explanation for the observed variations in the pricing schemes across publishers. Using a new “uncompromised” equilibrium refinement, we also demonstrate that the hybrid scheme can emerge as an equilibrium choice in a wide range of conditions. In addition to explaining the co-existence of multiple pricing schemes and the growing popularity of hybrid pricing schemes, our study also provide prescriptive guidelines for firms making choices among different pricing schemes.

Performance-based financing inlow-and middle-income countries

The pay-for-performance (P4P) tool has been used in low and middle-income countries in order to improve the performance of health-care providers. It helps to improve the quality of care and efficiency but has a drawback that it has a focus on a single condition and do not reflect the complexity of caring for patients with multiple conditions. To assess the impact of P4P on utilization of health service and quality of care in low- and middle- income countries. Different documents, papers, reports and literature were searched to assess the impact P4P on utilization and quality of health services and used Google search engine for this purpose. Analysis of the papers and project documents from 2002 to 2012 was conducted. The P4P schemes range from very large national programs to localized pilots and has been successfully implemented in post-conflict/fragile areas. Pay for performance model implemented in Dera ghazi Kahn district in Pakistan through free of cost vouchers given to pregnant women for antenatal checkup and transport facilities. The facility based deliveries increased from 20 to 90%. In Morocco, P4P model implemented through paid to the physicians for quality of care, screening of cervical cancer increased from 1.7 to 5.3% and hemoglobin A1c increases from 0.2 to 2.1%. Pay for performance increase the utilization of health services and quality of health services but it is constrained by certain challenges such as immature non-governmental international organizations (NGO) service sector with weak managerial and technical capacity, conditional cash transfers to households in countries with a large proportion of the population considered poor.

Information Asymmetry and Hybrid Advertising

Pay-for-performance (P4P) pricing schemes such as pay per click and pay per action have increased in popularity in Internet advertising. Meanwhile, pay-per-impression (PPI) schemes persist, and several publishers have begun to offer a hybrid mix of PPI and P4P schemes. Given the proliferation of pricing schemes, this study examines the optimal choices for publishers. The authors highlight two-sided information asymmetries in online advertising markets and the consequent trade-offs faced by a high-quality publisher using P4P schemes. Pay-for-performance schemes enable a high-quality publisher to reveal its superior quality; however, such schemes may incur allocative inefficiencies stemming from inaccurate estimates of advertiser qualities. The authors identify conditions under which a publisher may opt for a PPI, P4P, or hybrid scheme and, in doing so, provide theoretical explanations for the observed variations in the pricing schemes and the increasing popularity of hybrid schemes. Using a new “uncompromised” equilibrium refinement, the authors find that the hybrid scheme can emerge as an equilibrium choice in a variety of conditions. In addition, they provide prescriptive guidelines for firms choosing between different pricing schemes.

Intrinsic and extrinsic motivations in primary care: An explanatory study among French general practitioners

BackgroundLike many other OECD nations, France has implemented a pay-for-performance (P4P) model in primary care. However, the benefits have been debated, particularly regarding the possibly undesirable effects of extrinsic motivation (EM) on intrinsic motivation (IM). ObjectiveTo examine the relationship between French GPs’ IM and EM based on an intrinsic motivation composite score (IMCS) developed for this purpose. If a negative relationship is found, P4P schemes could have side effects on GPs’ IM that is a key determinant of quality of care. MethodFrom data on 423 GPs practicing in a region of France, IM indicators are selected using a multiple correspondence analysis and aggregated from a multilevel model. ResultsSeveral doctors’ characteristics have significant impacts on IMCS variability, especially group practice and salaried practice. Qualitative EM variables are negatively correlated with the IMCS: GPs who report not being satisfied with their income or feeling “often” constrained by patients’ requests in terms of consultations length and office appointments obtain a lower mean IMCS than other GPs. ConclusionOur results provide a cautionary message to regulators who should take into account the potential side effects of increasing EM through policies such as P4P.

10 best resources on … pay for performance in low- and middle-income countries

Pay for performance (P4P) is defined as the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target (Eichler 2006). In recent years, P4P has received considerable attention as an innovative health system model to increase the use, quality and efficiency of health care services in lowand middle-income countries (LMIC). In addition, P4P is considered as a means to progress towards achieving the health-related Millennium Development Goals (MDGs) (Montagu and Yamey 2011). The term P4P is used interchangeably with other terms such as performance incentives, results-based financing (RBF) and performance-based financing (PBF) (Eichler 2006; Oxman and Fretheim 2008; Witter et al. 2012). P4P schemes can operate on either the supply or demand sides of health service provision (Eichler 2006; Oxman and Fretheim 2008). Incentives can be targeted at: (i) health care recipients, (ii) individual health care providers, (iii) health care facilities, (iv) private sector organizations, and (v) governments or public sector organizations (Oxman and Fretheim 2008). This paper aims to share some of the current resources on the application of P4P in LMIC, highlighting concept papers, systematic reviews, recent empirical studies and debate that are considered to provide a holistic view of P4P schemes. As some of the broadly defined P4P concepts do not consider demand-side P4P (Lagarde et al. 2010), the selection of resources in this article focuses largely on supply-side P4P schemes.

Pay-for-performance in disease management: a systematic review of the literature

BackgroundPay-for-performance (P4P) is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. P4P is a payment model that rewards healthcare providers for meeting pre-established targets for delivery of healthcare services by financial incentives. Based on their performance, healthcare providers receive either additional or reduced payment. Currently, little is known about P4P schemes intending to improve delivery of chronic care through disease management. The objectives of this paper are therefore to provide an overview of P4P schemes used to stimulate delivery of chronic care through disease management and to provide insight into their effects on healthcare quality and costs.MethodsA systematic PubMed search was performed for English language papers published between 2000 and 2010 describing P4P schemes related to the implementation of disease management. Wagner's chronic care model was used to make disease management operational.ResultsEight P4P schemes were identified, introduced in the USA (n = 6), Germany (n = 1), and Australia (n = 1). Five P4P schemes were part of a larger scheme of interventions to improve quality of care, whereas three P4P schemes were solely implemented. Most financial incentives were rewards, selective, and granted on the basis of absolute performance. More variation was found in incented entities and the basis for providing incentives. Information about motivation, certainty, size, frequency, and duration of the financial incentives was generally limited. Five studies were identified that evaluated the effects of P4P on healthcare quality. Most studies showed positive effects of P4P on healthcare quality. No studies were found that evaluated the effects of P4P on healthcare costs.ConclusionThe number of P4P schemes to encourage disease management is limited. Hardly any information is available about the effects of such schemes on healthcare quality and costs.

Challenges and directions for nursing in the pay-for-performance movement.

Pay-for-performance (P4P) initiatives attempt to drive quality of care by aligning desired care processes and outcomes with reimbursement. P4P schemes have emerged at a time of great concern about safety and quality in health care and in the face of a growing nurse shortage. This article discusses the state of the literature linking structures for providing nursing care, measures of process heavily favored in P4P initiatives, and patient outcomes and outlines how P4P is expected to affect nursing practice. It also presents directions for managing practice settings to cope with P4P and for steering nursing's involvement in this area of health policy. As implementation broadens, it remains to be seen whether unintended consequences emerge or whether nurses are successful in using the programs and the data sets that result from them to justify investments in nursing services and solidify the profession's position.