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Original Investigation |

Evaluating a Pay-for-Performance Program for Medicaid Children in an Accountable Care Organization

Sean Gleeson, MD1,2,3; Kelly Kelleher, MD1,2,3; William Gardner, PhD4
[+] Author Affiliations
1Partners for Kids, Columbus, Ohio
2Department of Pediatrics, Ohio State University, Columbus
3Nationwide Children’s Hospital, Columbus, Ohio
4Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
JAMA Pediatr. 2016;170(3):259-266. doi:10.1001/jamapediatrics.2015.3809.
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Importance  Pay for performance (P4P) is a mechanism by which purchasers of health care offer greater financial rewards to physicians for improving processes or outcomes of care. To our knowledge, P4P has not been studied within the context of a pediatric accountable care organization (ACO).

Objective  To determine whether P4P promotes pediatric performance improvement in primary care physicians.

Design, Setting, and Participants  This retrospective cohort study was conducted from January 1, 2010, to December 31, 2013. A differences-in-differences design was used to test whether P4P improved physician performance in an ACO serving Medicaid children. Data were obtained from 2966 physicians and 323 812 patients. Three groups of physicians were identified: (1) community physicians who received the P4P incentives, (2) nonincentivized community physicians, and (3) nonincentivized physicians employed at a hospital.

Intervention  Pay for performance.

Main Outcomes and Measures  Healthcare Effectiveness Data Information Set measure rates for preventive care, chronic care, and acute care primary care services. We examined 21 quality measures, 14 of which were subject to P4P incentives.

Results  There were 203 incentivized physicians, 2590 nonincentivized physicians, and 173 nonincentivized hospital physicians. Among them, the incentivized community physicians had greater improvements in performance than the nonincentivized community physicians on 2 of 2 well visits (largest difference was for adolescent well care: odds ratio, 1.05; 99.88% CI, 1.02-1.08), 3 of 10 immunization-incentivized measures (largest difference was for inactivated polio vaccine: odds ratio, 1.14; 99.88% CI, 1.07-1.21), and 2 nonincentivized measures (largest difference was for rotavirus: odds ratio, 1.11; 99.88% CI, 1.04-1.18). The employed physician group at the hospital had greater improvements in performance than the incentivized community physicians on 8 of 14 incentivized measures and 1 of 7 nonincentivized measures (largest difference was for hepatitis A vaccine: odds ratio, 0.34; 99.88% CI, 0.31-0.37).

Conclusions and Relevance  Pay for performance resulted in modest changes in physician performance in a pediatric ACO, but other interventions at the disposal of the ACO may have been even more effective. Further research is required to find methods to enhance quality improvements across large distributed pediatric health systems.

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Figure 1.
Odds Ratios Representing the Interactions Between the Years’ Effects and the Incentivized vs Nonmembers’ Effects

An odds ratio greater than 1 means that improvement in performance for the incentivized group was greater than the improvement for the nonmember physicians. ADHD indicates attention-deficit/hyperactivity disorder; DTP, diphtheria, tetanus toxoids, and pertussis vaccine; HEDIS, Healthcare Effectiveness Data Information Set; IPV, inactivated polio vaccine; MMR, measles, mumps, and rubella; Td, tetanus-diphtheria toxoids; and Tdap, tetanus, diphtheria, and pertussis.

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Figure 2.
Odds Ratios Representing the Interactions Between the Years’ Effects and the Incentivized vs Nationwide Children’s Hospital Effects

An odds ratio greater than 1 means that improvement in performance for the incentivized group was greater than the improvement for the Nationwide Children’s Hospital physicians. ADHD indicates attention-deficit/hyperactivity disorder; DTP, diphtheria, tetanus toxoids, and pertussis vaccine; HEDIS, Healthcare Effectiveness Data Information Set; IPV, inactivated polio vaccine; MMR, measles, mumps, and rubella; Td, tetanus-diphtheria toxoids; and Tdap, tetanus, diphtheria, and pertussis.

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