Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 186-188 (doi:10.1542/peds.2007-1158)
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COMMENTARY

Pay-for-Performance in Pediatrics: Proceed With Caution

Alyna T. Chien, MD, MSa and R. Adams Dudley, MD, MBAb

a Sections of General Pediatrics and Community Health Sciences, Department of Pediatrics, University of Chicago, Chicago, Illinois
b Divisions of Pulmonary and Critical Care and Institute for Health Policy Studies, University of California, San Francisco, California

In response to overwhelming evidence of significant quality problems within adult and pediatric health care, pay-for-performance programs have proliferated rapidly in adult care settings and are beginning to spread into pediatrics.1–6 Outpatient pediatric health care is being targeted by performance incentives in all 11 of the state Medicaid programs that currently use performance-incentive strategies and 33 of the 93 performance-incentive programs listed in the Leapfrog Compendium (the largest publicly available listing of performance-incentives programs in the country).7,8

We recognize that the current payment system contributes to our problems with quality, and we agree with the cautionary tone and measured approach suggested by Profit et al9 in the May 2007 issue of Pediatrics when considering whether performance incentives, in the form of pay-for-performance and/or public reporting, should be implemented to promote the quality of care provided by NICUs.

Because these programs require tremendous effort on the part of a wide variety of stakeholders (employers, health plans, health care organizations, and physicians), it is important to consider whether they are worth the effort. Current evidence indicates that performance incentive strategies may only be modestly effective,10–12 are not necessarily connected to better outcomes,13,14 and can yield undesirable unintended consequences.15–20

We stress 3 general and 2 pediatric-specific issues for those considering the use of this strategy in pediatrics. The purpose of these cautionary points is to make sure that physicians, program designers, and policy makers are aware that there are risks to using performance incentives in health care and that certain performance-incentive tactics developed for adult health care will not translate well to pediatrics.


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Recently, 3 sets of authors systematically reviewed the empirical evidence regarding performance-incentive programs in health care by using similar search and inclusion criteria.10,11,17 Although the majority of this literature assessed whether performance incentives yield their intended consequences, a small but significant handful of studies also evaluated performance incentives for their unintended effects.

  1. Performance incentives can improve documentation without changing underlying quality. Within the small but growing literature on performance incentives, 2 studies indicated that performance incentives improve documentation without changing the underlying quality of care.21,22
  2. Performance incentives can merely reward those already doing well. As part of the evaluation of a prototypical performance incentive program implemented in California and the Pacific Northwest, 1 study demonstrated that the vast majority of the $3.4 million in financial incentives paid to medical groups went to those who had higher baseline performance and improved the least.20
  3. Performance incentives can alter how willing physicians and/or health care organizations are to care for minorities and the medically complicated. An evaluation of the coronary artery bypass graft report-card effort in New York State found that black and Hispanic patients received coronary artery bypass grafts less often than their white counterparts after public reporting began.19 Additionally, a study of patients being treated for substance abuse in Maine showed that patients with the most severe substance abuse problems were less likely to be treated after Maine's Office of Substance Abuse introduced financial incentives for improving abstinence, increasing employability, and reducing family and legal problems.18


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The performance incentive programs that are proliferating in adult health care emphasize rewarding disease-specific processes of health care that are connected to better outcomes (eg, ß blockers after acute myocardial infarction). Program designers have focused on evidence-based disease-specific processes of care for common adult conditions because providers presumably control these processes better than health care outcomes (which depend on numerous factors outside a provider's control, such as patient preference and adherence).23–26 This general strategy faces critical challenges in pediatrics for 2 basic reasons:

  1. The low prevalence of disease in pediatrics enlarges the sample-size problem in performance-incentive programs. Limited sample sizes at the provider level are already an issue for programs that target common adult conditions.15 This problem would be dramatically magnified in pediatrics. Children with condition-specific health care needs are a fraction of the total child population that is already one quarter that of the adult population.27 Those who implement pediatric-focused incentive strategies will need to pay even greater attention to methods of aggregating measures across conditions or to developing performance measures that reflect more general processes of health care (eg, measures that reflect patient-centeredness or care coordination).
  2. The paucity of evidence-based quality-of-care metrics poses a greater risk of setting standards of care that are not connected to outcomes. It also increases the reliance on consensus-driven guidelines and poses a greater risk of setting standards that are not objective.28–30 Pediatric strategies will need to exert an even greater effort to make sure that goals are meaningful, realistic, and achievable by providers working in a wide range of settings. Special care should be taken to include solo and/or small group providers and those who work in less-resourced rural or urban settings.

Given the recent explosion of interest in the use of performance incentives and the substantial evidence that quality is poor under the current payment system, it is reasonable to consider whether this strategy will be helpful for improving the quality of pediatric health care. The inherent risks and challenges, which are enhanced in pediatrics, make it important to think carefully about alternatives to existing performance strategies. Researchers, physicians, and policy makers must think creatively about interventions that foster providers’ natural sense of altruism. Developing methods that support intrinsic motivation may prove to be more fruitful than performance incentives in guaranteeing long-term and sustainable improvements to our health care system.31


   FOOTNOTES
 
Accepted Apr 27, 2007.

Address correspondence to Alyna T. Chien, MD, MS, 5841 S Maryland Avenue, MC 2007, Chicago, IL 60637. E-mail: alyna_chien{at}yahoo.com

Financial Disclosure: Dr Dudley's work on this article was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.


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  6. Centers for Medicaid and Medicare Services. Medicare pay-for-performance demonstration shows significant quality of care improvement at participating hospitals. Available at: www.cms.hhs.gov/apps/media/press/release.asp?Counter=1441. Accessed November 23, 2005
  7. Centers for Medicaid and Medicare Services, Center for Health Care Strategies. Descriptions of selective performance incentive programs. Available at: www.cms.hhs.gov/smdl/downloads/StatePerformanceIncentiveChart040606.pdf. Accessed November 23, 2005
  8. Leapfrog Group. The Leapfrog compendium. Available at: http://ir.leapfroggroup.org/compendium. Accessed March 31, 2007
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  16. Chien AT, Chin MH, Davis AM, Casalino LP. Pay-for-performance, public reporting and racial disparities in health care: how are programs being designed? Med Care Res Rev. 2007; In press
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  26. American College of Physicians. Linking physician payments to quality care. Available at: www.acponline.org/hpp/link_pay.pdf. Accessed September 7, 2006
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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