History Bias, Study Design, and the Unfulfilled Promise of Pay-for-Performance Policies in Health Care

Figure 1. Mean percentage of patients achieving a selected quality indicator — a target total cholesterol level of ≤5 mmol/L— in a sample of family practices that participated in a study evaluating the effect of the United Kingdom’s pay-for-performance policy. Dashed line indicates when the pay-for-performance policy was implemented (April 2004). Figure is based on data extracted from Table 2 of Tahrani AA, McCarthy M, Godson J, Taylor S, Slater H, Capps N, et al. Diabetes care and the new GMS contract: the evidence for a whole county. Br J Gen Pract 2007;57(539):483–5 (19). 

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Figure 2. Mean clinical quality scores for diabetes at 42 practices participating in a study evaluating the effect of the United Kingdom’s pay-for-performance policy. The scale for scores ranges from 0% (no quality indicator was met for any patient) to 100% (all quality indicators were met for all patients). Dashed line indicates when the pay-for-performance policy was implemented (April 2004). Figure is based on data extracted from Table 1 in Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361(4):368–78 (21).

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Figure 3. Percentage of study patients who began antihypertensive drug treatment from January 2001 through July 2006. Dashed line indicates when the United Kingdom’s pay-for-performance policy was implemented (April 2004). Figure is based on data extracted from bottom panel, Figure 3, in Serumaga B, Ross-Degnan D, Avery AJ, Elliott RA, Majumdar SR, Zhang F, et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011;342:d108 (22).

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Figure 4. Mortality at 30 days among all hospitals examined before (from first quarter 2002) and after (through fourth quarter 2009) implementation of a pay-for-performance intervention (Premier Hospital Quality Incentives Demonstration [HQID]), which targeted 4 conditions beginning in late 2003: acute myocardial infarction, congestive heart failure, and pneumonia, and patients who underwent coronary artery bypass grafting. Changes at hospitals participating in the pay-for-performance intervention (Premier) were similar to changes at hospitals not participating (non-Premier) for all 4 conditions. Figure is reproduced from Jha AK, Joynt KE, Orav EJ, Epstein AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med 2012;366(17):1606–15 with permission from the New England Journal of Medicine (23).

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Figure 5. Mean low-density lipoprotein (LDL) cholesterol levels at baseline and 12-month follow-up in an intervention (pay-for-performance) group (in which incentives were provided to physicians) and a control group (no pay-for-performance). The intervention was conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Patients in the control group achieved a mean reduction of 25.1 mg/dL in LDL cholesterol levels from a baseline of 161.5 mg/dL. Patients in the pay-for-performance group achieved a mean reduction of 27.9 mg/dL from a baseline of 159.9 mg/dL. The difference between the 2 groups was neither statistically significant nor clinically meaningful. Figure is based on data extracted from Asch DA, Troxel AB, Stewart WF, Sequist TD, Jones JB, Hirsch AG, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA 2015;314(18):1926–35 (26).

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